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The role of the medical health officer in British Columbia Loewen, Dale Raymond 1979

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THE ROLE OF THE MEDICAL HEALTH OFFICER IN BRITISH COLUMBIA by DALE RAYMOND LOEWEN, Queen's U n i v e r s i t y ,  M.D. 1966  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE  in THE FACULTY OF GRADUATE STUDIES Department of H e a l t h Care and Epidemiology We a c c e p t t h i s t h e s i s as conforming to required standard  THE UNIVERSITY OF BRITISH COLUMBIA January, (£)  1979  Dale Raymond Loewen, 1979  In p r e s e n t i n g t h i s  thesis  in p a r t i a l  fulfilment of  the requirements f o r  an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, the L i b r a r y s h a l l I  f u r t h e r agree  make it  freely available  that permission  for  I agree  r e f e r e n c e and  f o r e x t e n s i v e copying o f  this  that  study. thesis  f o r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s of  this  representatives. thesis  It  is understood that  f o r f i n a n c i a l gain s h a l l  written permission.  Department of The U n i v e r s i t y o f B r i t i s h  2075 Wesbrook Place Vancouver, Canada V6T 1W5  Date  Columbia  copying or p u b l i c a t i o n  not be allowed without my  ii  ABSTRACT  The r o l e o f t h e M e d i c a l H e a l t h O f f i c e r  (M.H.O.) i n B r i t i s h Columbia i s ex-  p l o r e d i n t h i s t h e s i s , l o o k i n g f o r consensus on the "job The  e v a l u a t i o n o f t h i s brand  description."  o f community p h y s i c i a n i s examined i n a l i t -  e r a t u r e review which c o n s i d e r s h i s f u n c t i o n i n the t h r e e c o u n t r i e s o f B r i t a i n , the U n i t e d S t a t e s and Canada.  Some a s s o c i a t e d d i s c u s s i o n s o f community h e a l t h  s e r v i c e s i n these c o u n t r i e s i s e v i d e n t . i s a l s o e x p l o r e d as a n e c e s s a r y  Education of the Medical Health  component i n assuming t h i s r o l e  Officer  description.  The d i v e r s i t y o f r o l e s as engendered i n t h e Canadian p r o v i n c e s i s r e l a t e d t o the l e g a l and a d m i n i s t r a t i v e p o s i t i o n o f t h e B r i t i s h Columbia M e d i c a l Officer.  Health  The study g e n e r a l l y examines the l e v e l o f consensus t h a t has e x i s t e d  i n t e r n a t i o n a l l y and n a t i o n a l l y on t h e r o l e o f the M e d i c a l H e a l t h O f f i c e r and specifically  t h e l e v e l o f consensus amongst B r i t i s h Columbia M e d i c a l  Health  Officers. A survey q u e s t i o n n a i r e was m a i l e d t o a l l p r o v i n c i a l , r e g i o n a l and c i t y M e d i c a l H e a l t h O f f i c e r s i n B r i t i s h Columbia t o e l u c i d a t e t h e i r o p i n i o n s and i d e a s on what t h e j o b d e s c r i p t i o n e n t a i l s and what they f e e l i t should be. The response  r a t e o v e r a l l was seventeen  out o f twenty o r e i g h t y - f i v e  percent.  S e l e c t i o n , e d u c a t i o n and e x p e r i e n c e o f M e d i c a l H e a l t h O f f i c e r s i n B r i t i s h Columbia i s examined i n d e t a i l .  A t t i t u d e s about the p o s i t i o n and how i t r e -  l a t e s to t h e r e s t o f t h e m e d i c a l  community a r e f e l t  i n t e g r a t i o n o f community medicine r o l e d e s c r i p t i o n i s d i v i d e d mainly  t o be important  w i t h the r e s t o f medicine  a s p e c t s to  i n general.  The  into Administration (Health Unit D i r e c t o r  r o l e ) and D i r e c t S e r v i c e s (Community P h y s i c i a n ) r o l e .  The H e a l t h  Officer  iii  ( l e g i s l a t e d o f f i c e r r o l e ) i s o u t l i n e d as i t o c c u r s i n B r i t i s h Columbia but t h i s area i s n o t pursued  i n d e t a i l because i t c o u l d form t h e substance  o f a complete  study i n i t s e l f . The r e s u l t s i n d i c a t e d a l a c k o f consensus on t h e r o l e o f t h e M e d i c a l Officer. of  I n B r i t i s h Columbia t h e v a r i a b l e r o l e i s found  Health  t o be more a f u n c t i o n  p e r s o n a l p r e f e r e n c e and r e g i o n a l needs than a common s e t o f procedures and  practices. H i s t o r y r e v e a l e d a c o n s t a n t r e o r g a n i z a t i o n and r e - e v a l u a t i o n o f M e d i c a l H e a l t h O f f i c e r f u n c t i o n s a c c e l e r a t e d by r a p i d  technical, p o l i t i c a l  and s o c i a l  changes. The need f o r a c l e a r e r r o l e i s q u e s t i o n e d . felt ing  The M e d i c a l H e a l t h O f f i c e r i s  t o be a g e n e r a l i s t , h o p e f u l l y w i t h the v e r s a t i l i t y  to d i r e c t t h e " c o n f l i c t -  g o a l s " o f h e a l t h systems i n t o some k i n d o f o r g a n i z a t i o n a l sense.  outlook i s f e l t  t o be an a s s e t i n t h i s  H i s broad  regard.  F i v e main recommendations r e s u l t e d from t h e study w i t h r e s p e c t to t h e B r i t i s h Columbia M e d i c a l H e a l t h O f f i c e r .  These were:  1. r e - e v a l u a t i o n o f the e d u c a t i o n a l program, p e r i o d i c a l l y ; 2. e l i m i n a t i o n o f t h e m a r g i n a l l y u s e f u l a d m i n i s t r a t i v e f u n c t i o n s of  t h e M e d i c a l H e a l t h O f f i c e r by expansion  Supervisor  of the O f f i c e  role;  3. r e - e v a l u a t i o n ' o f t h e s e l e c t i o n p r o c e s s f o r B r i t i s h Medical Health 4.  establishment via  Columbia  Officers; of c l o s e r formal l i a i s o n with " c l i n i c a l  medicine"  t h e BCMA t o e l i m i n a t e t r a d i t i o n a l b a r r i e r s between t h e two  iv  groups and t o expand the r o l e o f community medicine and; 5. requirements  t h a t a s s u r e new M e d i c a l H e a l t h O f f i c e r s  will  o b t a i n t h e F.R.C.P. q u a l i f i c a t i o n s t o m a i n t a i n e q u a l i t y and Finally,  c r e d i b i l i t y w i t h the c l i n i c a l p h y s i c i a n s . i t i s felt  t h a t t h e r e w i l l be ongoing e v a l u a t i o n and assessment  of the M e d i c a l H e a l t h O f f i c e r r o l e without even d e s i r a b l e . The  T h i s i s not f e l t  consensus ever b e i n g a c h i e v a b l e o r  t o a l t e r h i s c o n t r i b u t i o n t o h e a l t h systems.  q u e s t i o n , "What l e v e l o f consensus i s t h e r e among B r i t i s h  M e d i c a l H e a l t h O f f i c e r s about t h e i r r o l e ? " has been answered.  Columbia  There i s none.  V  TABLE OF CONTENTS CHAPTER I II  PAGE INTRODUCTION LITERATURE REVIEW  1 .  3  The F o r c e s o f M e d i c i n e  3  Organization of Public Health  4  The R o l e o f t h e M e d i c a l H e a l t h O f f i c e r  11  E d u c a t i o n o f M e d i c a l H e a l t h O f f i c e a r i n U.K  15  E d u c a t i o n o f the M e d i c a l H e a l t h O f f i c e r i n the U n i t e d S t a t e s . 18  III IV  E d u c a t i o n o f M e d i c a l H e a l t h O f f i c e r s i n Canada  23  P r o v i n c i a l V a r i a t i o n s i n P u b l i c H e a l t h and M e d i c a l H e a l t h O f f i c e r Roles  24  L e g a l and A d m i n i s t r a t i v e P o s i t i o n o f the B.C. M e d i c a l H e a l t h O f f i c e r i n the P r o v i n c i a l P u b l i c H e a l t h S e r v i c e  31  METHOD  36  ANALYSIS OF DATA  38  D e s c r i p t i o n of Population  38  L e v e l s o f Consensus  39  a. A l l o c a t i o n o f E f f o r t  39  b. P r e p a r a t i o n f o r M e d i c a l H e a l t h O f f i c e r Role  43  c. Role o f the M e d i c a l H e a l t h O f f i c e r i n T o t a l M e d i c a l Community  47  d. A t t i t u d e s About Work and S e t t i n g  50  e. New D i r e c t i o n s i n S e r v i c e  50  L e v e l s o f Consensus Among Sub Groups  52  Selection of Medical Health O f f i c e r s  53  vi  TABLE OF CONTENTS CHAPTER V  PAGE SUMMARY AND RECOMMENDATIONS  54  BIBLIOGRAPHY  60  APPENDIX  65  Questionnaire  66  L e t t e r to Provinces  81  vii  LIST OF TABLES f  TABLE I II III IV  V VI VII  VIII  IX  PAGE Age  D i s t r i b u t i o n of B r i t i s h Columbia M e d i c a l H e a l t h O f f i c e r s  XI XII XIII  XIV XV  XVI  38  Year of G r a d u a t i o n  38  L e v e l of Q u a l i f i c a t i o n  38  M e d i c a l H e a l t h O f f i c e r s D i v i s i o n of Labour With Respect  to  P e r c e n t of Time A l l o c a t e d to A d m i n i s t r a t i o n  40  E s s e n t i a l A d m i n i s t r a t i v e F u n c t i o n s as L i s t e d by Respondents ....  40  E s s e n t i a l D i r e c t S e r v i c e s as L i s t e d by Respondents  41  M a r g i n a l l y U s e f u l A d m i n i s t r a t i v e F u n c t i o n s - Those F u n c t i o n s Which M e d i c a l H e a l t h O f f i c e r s Would P r e f e r to Delegate to Someone E l s e  41  How M e d i c a l H e a l t h O f f i c e r s Would Use Were A v a i l a b l e  42  E x t r a Time I f I t  Lay A d m i n i s t r a t i v e F u n c t i o n s - Those F u n c t i o n s Which Could Delegated  X  ...  Be  to a Lay A d m i n i s t r a t o r  42  R a t i n g o f Areas of T r a i n i n g  44  Relevancy  45  to Jobs of Areas of T r a i n i n g  D e f i c i e n t Areas of T r a i n i n g P r e v i o u s E x p e r i e n c e Recommended f o r Community M e d i c i n e Average Number of Years Recommended Experience  45 With  i n Other F i e l d s by C u r r e n t M e d i c a l H e a l t h O f f i c e r s  46 ..  46  Areas of C l i n i c a l P r a c t i c e That Could be D e a l t With i n the Health Unit  48  What M e d i c a l H e a l t h O f f i c e r s Think C l i n i c i a n s Regard as Areas of I n t e r f e r e n c e by the H e a l t h U n i t  48  viii  LIST OF TABLES  TABLE XVII  XVIII XIX XX  PAGE How M e d i c a l H e a l t h O f f i c e r s  Think C l i n i c i a n s Could Use the  M e d i c a l H e a l t h O f f i c e r More E f f e c t i v e l y  49  H e a l t h U n i t Programs i n Need of C r i t i c a l Review  51  D i s e a s e s M e r i t i n g More A t t e n t i o n by M e d i c a l H e a l t h O f f i c e r s and Those With F e a s i b l e Programs to A t t a c k Them Need f o r F.R.C.P. i n Community M e d i c i n e as Dependent on I n d i v i d u a l L e v e l Achieved  51 52  1  CHAPTER I INTRODUCTION  There i s a c o n s i d e r a b l e d i f f e r e n c e o f o p i n i o n about t h e r o l e o f t h e M e d i c a l Health O f f i c e r .  D i f f e r e n t p o i n t s o f view have been expressed  about what M e d i c a l  H e a l t h O f f i c e r s s h o u l d be doing and how they s h o u l d f i t i n t o t h e o v e r a l l  system  of h e a l t h c a r e . R e g i o n a l needs, c u l t u r e , p e r s o n a l p r e f e r e n c e s and a host o f " p a r o c h i a l " p r e s s u r e s shape and determine t h e M e d i c a l H e a l t h O f f i c e r s ' r o l e and a c t as f o r c e s which oppose t h e development o f a common r o l e . The  i s s u e then,  i s whether r e g i o n a l demands d i c t a t e t h e r o l e or whether a  common s e t o f procedures  and p r a c t i c e s transends  r e g i o n a l boundaries,  and s e r v e  as t h e b a s i c components o f a common r o l e . As a f i r s t  s t e p i n d e t e r m i n i n g whether f u n c t i o n s t r a n s c e n d boundaries o r  are d i c t a t e d by them, we must l o o k a t what M e d i c a l H e a l t h O f f i c e r s a r e doing and how they view t h e i r f u n c t i o n s . even i f i t doesn't  T h i s w i l l g i v e us some v a l u a b l e  insights  answer t h e q u e s t i o n on whether a common r o l e f o r M e d i c a l  H e a l t h O f f i c e r s can emerge. Has  t h e r o l e o f t h e M e d i c a l H e a l t h O f f i c e r ever been d e f i n e d c l e a r l y ?  What l e v e l of consensus i s t h e r e among B r i t i s h Columbia M e d i c a l H e a l t h  Officers  about t h e i r r o l e ? T h i s t h e s i s w i l l examine the l e v e l o f consensus t h a t has e x i s t e d i n t e r n a t i o n a l l y and n a t i o n a l l y .  S p e c i f i c a l l y this research w i l l  explore the l e v e l  o f consensus amongst B r i t i s h Columbia M e d i c a l H e a l t h O f f i c e r s on t h e i r The  l i t e r a t u r e review  looks at P u b l i c Health  (Community M e d i c i n e )  role. and the  M e d i c a l H e a l t h O f f i c e r from t h e i r development i n B r i t a i n , t h e U n i t e d S t a t e s , Canada and B r i t i s h Columbia.  Q u e s t i o n n a i r e data from B r i t i s h Columbia M e d i c a l  2  Health O f f i c e r s  i s collected  and a n a l y s e d and f i n a l l y  c o n c l u s i o n s and recommen-  d a t i o n s a r e drawn based on the l i t e r a t u r e and on consensus about the r o l e o f the M e d i c a l H e a l t h O f f i c e r i n B r i t i s h Columbia.  3  CHAPTER I I  t  LITERATURE REVIEW  In t h i s Chapter we w i l l  be examining the b e g i n n i n g s o f the M e d i c a l  O f f i c e r as p u b l i c h e a l t h evolved  from p r i v a t e p r a c t i c e i n B r i t a i n .  Health  The spread  of p u b l i c h e a l t h , now r e f e r r e d t o as community m e d i c i n e , from B r i t a i n to the United  S t a t e s and Canada i s e x p l o r e d  Health  O f f i c e r as i t emerges i n these c o u n t r i e s  larities  Health  The r o l e o f the M e d i c a l  i s contrasted  looking f o r simi-  and consensus on the j o b d e s c r i p t i o n .  The finally  and compared.  provinces  w i t h i n Canada a r e compared w i t h the same i d e a i n mind and  the l e g a l and a d m i n i s t r a t i v e  p o s i t i o n o f the B r i t i s h Columbia  Medical  O f f i c e r i s discussed.  1. M e d i c i n e and P u b l i c  Health  P u b l i c h e a l t h has e x i s t e d s i n c e t h e b e g i n n i n g o f m e d i c i n e i n some v a r y i n g form.  The mainstream o f m e d i c i n e i n v o l v e d  whose background s t r e t c h e d  to e a r l i e s t of w r i t t e n records.  o r i e n t e d and p a t i e n t o r i e n t e d . physician  the h i s t o r i c a l c l i n i c a l  (an i n d i v i d u a l ) should  physician,  He was i n d i v i d u a l  The H i p p o c r a t i c Oath i t s e l f , s t r e s s e d t h a t t h e live  i n p a r t n e r s h i p w i t h the p h y s i c i a n  (an i n -  d i v i d u a l ) who taught him the a r t , and the whole f l a v o u r o f the o a t h i s t h a t o f a r e l a t i o n s h i p between the i n d i v i d u a l p h y s i c i a n and h i s p a t i e n t . of y e a r s the i n d i v i d u a l has been coming t o the i n d i v i d u a l d o c t o r h u r t s h e r e " , and a s k i n g  For thousands saying: " I t  to be h e l p e d .  In much o f t h i s t r a d i t i o n a l m e d i c i n e , the p h y s i c i a n d i d n ' t unless  he was s i c k .  The w e l l man d i d n ' t  doctor  f r e q u e n t l y saw f a m i l y members i n good h e a l t h ,  see the p a t i e n t  c o n s u l t a p h y s i c i a n , but the f a m i l y thereby i n v o l v i n g  himself  4  i n preventive  m e d i c i n e and  i n d i v i d u a l s became s i c k . disease  obtaining  i n s i g h t s which would h e l p him when these  Public health,  i n the community r e q u i r e d  or p r o t e c t i o n from and  s t a t e involvement and  prevention  eventually  of  separated  from p r i v a t e p r a c t i c e or the mainstream. Community M e d i c i n e , the a p p l i c a t i o n of s c i e n t i f i c and to the p r o t e c t i o n and  improvement of the h e a l t h of the  n i z a t i o n , a c o n s c i o u s e f f o r t by h e a l t h has  also existed  d o c t o r s of Egypt and A r a b i a n c i t i e s and l i m i t e d by  authority.  I t has  r o l e has 2.  T h i s has  of p u b l i c  times, eg.  the  state  of  always, u n t i l r e c e n t l y , been  hampered by an  inadequate appre-  a l a c k of s o c i a l u n d e r s t a n d i n g .  an almost complete l a c k o f o r g a n i z a t i o n  Certainly,  f o r community h e a l t h  a secondary r o l e to the mainstream and  services.  consensus on  this  been l a c k i n g . Organization  of P u b l i c  Health  i n t e r n a t i o n a l or n a t i o n a l agreement on  Public health organization  t e r e s t o f those who  only  Thus, the r i c h i n England played they were convinced t h a t as w e l l as  has  had  those of the  to await the e n l i g h t e n e d  to "new  pastures"  but  a more a c t i v e p a r t  the d i s e a s e s  of s q u a l o r  of  public  self in-  been p r a c t i c e d  to more p l e a s a n t  pastures.  i n s a n i t a r y reform, once  might endanger t h e i r own  lives,  poor.  b e g i n n i n g s i n Europe were near the end  f l e c t i n g varying  the o r g a n i z a t i o n  a r e c a p a b l e o f g e t t i n g t h i n g s done, so i t has  when i t seemed to l e a d not  The  Some form of o r g a n i z a t i o n  the l a c k of t e c h n i c a l knowledge and  Is t h e r e health?  f o r orga-  Rome, the m e d i e v a l l e p r o s a r i a , s a n i t a r y i n s p e c t o r s  r e g u l a t i o n of b r o t h e l s .  always played  group - c a l l s  i n most s o c i e t i e s from the e a r l i e s t  c i a t i o n of the v a l u e of h e a l t h and t h e r e was  m e d i c a l knowledge  i d e o l o g i e s of the many p e o p l e s .  of the e i g h t e e n t h  century,  re-  Johann P e t e r Frank (1745-1821)  5  wrote about s o c i a l medicine c r a c y he l i v e d under.  as a p o l i c e measure - an e x p r e s s i o n o f the auto-  H i s i d e a s on hygiene  i n the classroom,  and p o v e r t y  as a cause o f i l l n e s s were way ahead o f h i s time but d i d l i t t l e sent day concern  f o r ' p a r t i c i p a t i o n by the people,  t h i n g s w i t h people In B r i t a i n , water t o p u r i f i e d  i n tune w i t h t h e i r  to r e f l e c t  pre-  l o c a l government o r doing  culture.'  Chadwick's (1800-1890) c i r c u l a t i o n o f v i t a l  fluids,  from pure  sewage, p r o t e c t e d water c o u r s e s , p i p e s , d r a i n s and sewers i n -  t a c t and i n v i o l a t e , r e t u r n a f t e r p u r i f i c a t i o n t o the s o i l - has been as momentous f o r man's p r o g r e s s as Harvey's d i s c o v e r y o f the c i r c u l a t i o n o f the b l o o d . If  he were a l i v e now he would s t i l l  f i n d n i n e - t e n t h s o f the world  s u f f e r i n g the  torments o f i n t e s t i n a l i n f e s t a t i o n s from which Europe and the New World, i n f o l l o w i n g h i s t e a c h i n g s , have escaped.  Not o n l y h i s s a n i t a t i o n , b u t t h e use o f  l o c a l government i n p u b l i c h e a l t h a d m i n i s t r a t i o n and t h e use o f t h e M e d i c a l H e a l t h O f f i c e r as a s p e c i a l i s t a d v i s o r gave r i s e t o f a r r e a c h i n g e f f e c t s .  The  appointment o f the M e d i c a l H e a l t h O f f i c e r soon became compulsory and t h e i r  ten-  ure o f o f f i c e p r o t e c t e d . Throughout Europe, North America and the B r i t i s h Dominions the g e n e r a l plan of organization followed.  However, w h i l e Europe gathered  i t s administra-  t i v e f o r c e s a t the c e n t r e and a t t a c k e d the problem o f how to get the s i c k ted,  England  and the New World got down t o Chadwick's s a n i t a t i o n w i t h t h e r e s -  p o n s i b i l i t y f i r m l y p l a c e d upon the s h o u l d e r s o f the l o c a l The  trea-  i n f l u e n c e o f England  on America was s t r i k i n g .  (1850) might e a s i l y have been w r i t t e n by Chadwick.  citizens.  The Shattuck  Shattuck  report,  f o l l o w e d the Eng-  l i s h r e p o r t i n most o f i t s main recommendations, i n c l u d i n g t h a t f o r f u l l M e d i c a l H e a l t h O f f i c e r s s p e c i a l l y t r a i n e d and q u a l i f i e d  time  i n p u b l i c h e a l t h and  6  independent  of p r i v a t e p r a c t i c e .  D e s p i t e the r e p o r t , however, the concept  of  a w e l l - o r g a n i z e d h e a l t h department, s u p e r v i s e d by a whole-time M e d i c a l H e a l t h O f f i c e r , was  not w i d e l y a p p l i e d i n the U n i t e d S t a t e s u n t i l  The Canadian e x p e r i e n c e has and e a r l i e r B r i t a i n ,  i n 1921.  because of a smallpox In 1951,  f o l l o w e d a s i m i l a r p a t t e r n t o the U n i t e d S t a t e s ,  i n the e s t a b l i s h m e n t of h e a l t h u n i t s .  which became a p r o v i n c e i n 1871, i n 1892  the 1920's.  the f i r s t M e d i c a l H e a l t h O f f i c e r was  epidemic.  G.R.F. E l l i o t  The  Columbia, appointed  f i r s t h e a l t h u n i t began i n Saanich  speaking on the e v o l v i n g r o l e , s t a t e d t h a t  "the h e a l t h u n i t must have a broad must l e a r n to understand  In B r i t i s h  approach to s o c i a l and  economic problems and  and a t t a c k m e d i c a l c a r e , poor housing, mental  hygiene,  a c c i d e n t s and o t h e r s . " The development of l o c a l h e a l t h u n i t s has been, to a l l appearances, haphazard everywhere. ered i n 1875. the 1920's.  In England,  they began i n 1831  In the U n i t e d S t a t e s , the span was Few  and  quite  the c o u n t r y was  from 1793,  cov-  i n Baltimore, u n t i l  t h i n g s , indeed, a r e so s t r i k i n g as v a r i a t i o n s i n development  of p u b l i c h e a l t h amongst c o u n t r i e s .  Denmark began g r a t u i t o u s treatment  V e n e r e a l D i s e a s e f o r a l l p a t i e n t s i n 1790 c o n c e n t r a t e d on s a n i t a t i o n i n 1848  - B r i t a i n d i d n ' t u n t i l 1916.  - France h a r d l y a p p r e c i a t e d i t u n t i l  A l s o , the extent of power w i e l d e d by the M e d i c a l H e a l t h O f f i c e r has  of Britain 1902. been  s t r i k i n g l y d i f f e r e n t , w i t h i n d i f f e r e n t c o u n t r i e s and o f t e n w i t h i n the same country.  (W.H.O. '75).  erned on the m a n a g e r i a l  The H e a l t h Commissioner i n a U n i t e d S t a t e s c i t y govsystem, making and  e x e c u t i n g h i s own  l i a b l e to removal by p o l i t i c a l whim, w i l l have enjoyed round  of l i f e  from  t h a t of a nominated o f f i c i a l  laws, but g e n e r a l l y  a very d i f f e r e n t  i n a European c o u n t r y .  daily The  7  B r i t i s h M e d i c a l O f f i c e r o f H e a l t h , whose duty i t was t o d i s c o v e r e v e r y t h i n g i n his  a r e a p r e j u d i c i a l t o t h e h e a l t h o f t h e p e o p l e was v i r t u a l l y independent o f  c o n t r o l from the c e n t r e and y e t the s e r v a n t o f a l o c a l l y e l e c t e d c o u n c i l w i t h its  own chairman.  I n Canada t h e r e i s a s i m i l a r i t y t o B r i t a i n b u t the M e d i c a l  H e a l t h O f f i c e r i s not t o t a l l y a t the mercy o f any l o c a l body because o f p r o v i n c i a l control.  There i s v a r i a t i o n here amongst t h e p r o v i n c e s and, as we w i l l  see, the r o l e s a r e changing  c o n t i n g e n t on p r o v i n c i a l governments, not l o c a l  sources o f power. In  machinery and c o n t e n t , p u b l i c h e a l t h - the b a s i c i n s t i t u t i o n c r e a t e d  and m a i n t a i n e d by s o c i e t y t o p r e s e r v e t h e l i f e and h e a l t h o f t h e people — i s , in  Europe and North America,  a many splendored garment.  developments i n comprehensive m e d i c a l c a r e have tended ment o f a common p a t t e r n . in  (W.H.O. '75). Recent to h a s t e n the d e v e l o p -  Most o f t h e c o u n t r i e s which began t h e i r p u b l i c h e a l t h  the n i n e t e e n t h c e n t u r y movement a r e once a g a i n i n t h e t h r o e s o f r e v o l u t i o n a r y  t h i n k i n g towards t h e newer g o a l o f s o c i a l m e d i c i n e , which i n v o l v e s p u b l i c h e a l t h in  c u r a t i v e medicine  and v i c e v e r s a .  The concept  o f good p u b l i c h e a l t h now de-  mands a f u l l m e d i c a l s e r v i c e , a t home and i n h o s p i t a l , a v a i l a b l e t o every zen i r r e s p e c t i v e o f the a b i l i t y  to pay.  citi-  B r i t a i n , A u s t r a l i a , New Zealand and  Canada a r e engaged more deeply i n o p e r a t i n g schemes o f m e d i c a l c a r e , f i n a n c e d by the S t a t e o r i n s u r a n c e , a c c o r d i n g to t a s t e . ing  These have r e s u l t e d i n i n c r e a s -  emphasis on t h e h o s p i t a l , a phenomenon which every c o u n t r y has e x p e r i e n c e d  to  some degree.  to  prevent  The f u t u r e i n Europe and North America may w e l l become a f i g h t  t h e h o s p i t a l from t a k i n g c o n t r o l .  On t h e c r e a t i o n o f a P u b l i c H e a l t h o r Community M e d i c i n e h e a l t h s t r u c t u r e , the World H e a l t h O r g a n i z a t i o n (W.H.O. '75) has come out w i t h f o u r  concepts  8  concerning i. ii.  the permanent framework.  U n i f i c a t i o n of p r e v e n t i v e and  c u r a t i v e medicine,  The need f o r u n i t y or c o n t r o l , where one body of the community needing  governing  the s e r v i c e c o - o r d i n a t e s  a l l measures o f p r e v e n t i o n , c a r e and r e s t o r a t i o n under one h e a l t h s e r v i c e , i s s t r e s s e d . iii.  (W.H.O.  '52)  There i s a need f o r l o c a l government w i t h l e g a l f o r autonomy of a c t i o n .  backing  Problems, when t h i s i s n ' t i n  e f f e c t have been e v i d e n t i n underdeveloped c o u n t r i e s , iv.  Finally,  i t has been s t a t e d t h a t "primacy of p r e v e n t i v e  medicine  i s to be m a i n t a i n e d  by h a v i n g h e a l t h minded r a t h e r  than d i s e a s e minded people r e s p o n s i b l e f o r o v e r a l l and  the d i r e c t i o n and  planning  a l l o c a t i o n of community r e s o u r c e s . "  Where the h o s p i t a l has been i n c l u d e d i n the a d m i n i s t r a t i o n , t h i s  offers  the b e s t o p p o r t u n i t y of p r e v e n t i n g h o s p i t a l s from becoming autonomous w i t h c o n t r o l l e d v e s t e d i n t e r e s t s i n c u r a t i v e medicine.  I t i s the M e d i c a l  un-  Health  O f f i c e r , r a t h e r than the H o s p i t a l O f f i c e r , t h a t s h o u l d p l a n . " P u b l i c h e a l t h i n Europe and North America i s a many splendoured  garment.  Power w i e l d e d by the M e d i c a l H e a l t h O f f i c e r between d i f f e r e n t c o u n t r i e s and the same country has been s t r i k i n g l y d i f f e r e n t . U n i t s has been q u i t e haphazard everywhere."  The  development of l o c a l  These statements  from the  in  Health  preceding  d i s c u s s i o n i n d i c a t e l a c k of agreement on the o r g a n i z a t i o n of p u b l i c h e a l t h and on the power base of the M e d i c a l H e a l t h  Officer.  9  R e u n i f i c a t i o n of C l i n i c a l Medicine To f u r t h e r confuse medicine  and  Public Health  t h i s l a c k of agreement, today p u b l i c h e a l t h and  are moving t o g e t h e r a g a i n .  In some p a r t s of the world  ready j o i n e d , i n o t h e r s they are s t i l l the advance towards the acceptance  apart.  they have a l -  There has been an uneveness of  of medicine  as a s o c i a l s c i e n c e , and  m e d i c a l and h o s p i t a l c a r e as an e s s e n t i a l agent i n p u b l i c h e a l t h . d i n a v i a n d o c t o r s have accepted  have fought of t h e i r  the U n i t e d S t a t e s of America and  r e a r g u a r d a c t i o n s to a v o i d what they c o n s i d e r to be an  of  While Scan-  a c o - o p e r a t i v e r o l e from the n i n e t e e n t h  onwards, the p r o f e s s i o n s i n England,  clinical  century France  infringement  liberties.  In 1920,  the Dawson Committee s a i d i n B r i t a i n ,  u n i f y p r e v e n t i v e and  c u r a t i v e medicine:  " P r e v e n t i v e and  not be s e p a r a t e d on any sound p r i n c i p l e , and  c u r a t i v e medicine  can-  i n any scheme, m e d i c a l s e r v i c e s  must be brought t o g e t h e r i n c l o s e c o - o r d i n a t i o n . w i t h i n the sphere  commenting on the need to  They must l i k e w i s e be brought  of the g e n e r a l p r a c t i t i o n e r whose a c t i v i t i e s  should  embrace  ® communal as w e l l as i n d i v i d u a l The most important  medicine."  e x p r e s s i o n , of t h i s l i n k a g e , i s i n r e l a t i o n to the work  o f the g e n e r a l p r a c t i t i o n e r , where m e d i c a l  c a r e , based on the f a m i l y u n i t ,  go hand i n hand w i t h h e a l t h promotion, p r o p h y l a x i s , h e a l t h e d u c a t i o n ,  can  rehabili-  ® t a t i o n and  " s t i m u l a t i o n of l o c a l i n t e r e s t  i n public health."  The b a r r i e r s between c l i n i c a l medicine h e a l t h o f f i c e r s and m e d i c a l c l i n i c a l p r a c t i c e and  and p u b l i c h e a l t h , between m e d i c a l  care a d m i n i s t r a t o r s a r e crumbling.  Teamwork of a l l  of t h a t w i t h the s o c i a l s e r v i c e s i s r e q u i r e d .  h e a l t h needs c l i n i c a l medicine  - c l i n i c a l medicine  Public  needs a community.  p r e s e n t s t r u c t u r e of h e a l t h s e r v i c e s r e f l e c t s h i s t o r y and  politics,  The  sectional  10  pressures,  sheer i n e r t i a , and i t has to c a t c h up now w i t h  terns of disease, unity physician  s e r v i c e and c a r e .  (medical  changes i n the p a t -  I n promoting t h e p u b l i c h e a l t h , the comm-  h e a l t h o f f i c e r ) must be d i r e c t l y concerned w i t h t h e  mass problems o f today and be a b l e t o draw from t h e community's r e s o u r c e s t o deal with  these,  have d e p o s i t e d "By  not be l i m i t e d  in his  to the need o f s e r v i c e s t h a t h i s t o r y happens t o  office.  f a r the most important t r e n d  i n f l u e n c i n g t h e f u t u r e r o l e o f the l o c a l  h e a l t h department and m e d i c a l h e a l t h o f f i c e r i n Canada i s the i n c r e a s i n g z a t i o n t h a t s o c i e t y w i l l no l o n g e r prevention  t o l e r a t e the o l d f a s h i o n e d  ( l o c a l h e a l t h department) and treatment  fessionals).  This s p l i t  d i v i s i o n between  ( h o s p i t a l and h e a l t h  pro-  i s s a i d t o be a waste o f time, e f f o r t and money."  More r e c e n t l y i n t h e U n i t e d  S t a t e s o f America i t has been s t a t e d t h a t t h e  p r i v a t e s e c t o r o f m e d i c a l care has demonstrated s e r i o u s i n a d e q u a c i e s  ® with  reali-  i n coping  0  such d i f f i c u l t i e s as m a l d i s t r i b u t i o n o f s e r v i c e s , q u a l i t y c o n t r o l and c o s t  d)  containments^  A survey o f l o c a l h e a l t h departments and t h e i r d i r e c t o r s i n 1977, l i s h e d t h a t o f f i c i a l p u b l i c h e a l t h a g e n c i e s a r e f a r too e x t e n s i v e t e n t l y overlooked United  i n the development o f the n a t i o n ' s  t o be c o n s i s -  health p o l i c i e s .  The  S t a t e s has i n p l a c e an unevenly o p e r a t i v e p u b l i c i n f r a s t r u c t u r e of comm-  u n i t y and p e r s o n a l h e a l t h s e r v i c e s - u n d e r s t a f f e d , nored.  estab-  underfunded and w i d e l y i g -  The p o s s i b l e b e n e f i t s t h a t might d e r i v e from c o r r e c t i n g these  needs c l o s e a t t e n t i o n . Reorganization of the B r i t i s h National Health  neglects  S e r v i c e i n A p r i l 1974 brought  jo about t h e c r e a t i o n o f community medicine as a s e r v i c e s p e c i a l t y In 1967 S i r George Godber had s t a t e d , " I t w i l l be lamentable to t h e f u t u r e  11  of  s o c i a l medicine  and g r a v e l y l i m i t i n g to the development of our s e r v i c e s i f  the p r e s e n t g e n e r a t i o n of a d m i n i s t r a t i v e d o c t o r s does not s e i z e the o p p o r t u n i t y now  opening  b e f o r e i t , of p r o v i d i n g i n every d i s t r i c t  who  w i l l promote the o r g a n i z a t i o n of m e d i c a l  v e n t i v e a s p e c t s and ministration." in  (Hunter  A Working P a r t y on M e d i c a l A d m i n i s t r a t o r s i n March 1970  (Todd R e p o r t )  Report;  and  5  the Report  a g a i n but  i n t e r e s t and  i n a clearer  role.  Officer  examine more s p e c i f i c a l l y the M e d i c a l H e a l t h O f f i c e r  attempting  f i n d consensus on h i s f u n c t i o n s , a. The  Britain e v o l v i n g r o l e of the M e d i c a l H e a l t h O f f i c e r can b e s t be seen by l o o k i n g ,  initially,  a t the B r i t i s h E x p e r i e n c e .  c e p t i o n to the f o r m i d a b l e genius his  on M e d i c a l  i s moving c l o s e r to the main-  i t seems t h i s has not y e t r e s u l t e d  3. The Role of the M e d i c a l H e a l t h  to  from a union of the Report  resulted  the r e o r g a n i z e d N a t i o n a l H e a l t h S e r v i c e . (N.H.S.)  of medicine  We w i l l now  pre-  of a Working P a r t y on M e d i c a l A d m i n i s t r a t o r s  P u b l i c h e a l t h has a t t r a c t e d new stream  c a r e i n a l l i t s c u r a t i v e and  i n l a r g e areas the e s s e n t i a l l y m e d i c a l p a r t of b e t t e r ad-  the emergence of "Community M e d i c i n e "  Education  the "community p h y s i c i a n "  The M e d i c a l H e a l t h O f f i c e r owes h i s con-  ChadwickT  The  reason,  or p r i n c i p a l reason,  mind, f o r the b i r t h of the M e d i c a l H e a l t h O f f i c e r was  not h u m a n i t a r i a n  in  but  economic, because i t would make sense i n the e f f e c t i v e o r d e r i n g of the p u b l i c h e a l t h system. W.H. but i t was  He  f e l t d i s e a s e was  Duncan was  the f i r s t  a waste of human r e s o u r c e s .  Medical Health O f f i c e r appointed,  i n January  1847  the appointment o f Simon i n London the f o l l o w i n g year which gave the  o f f i c e the stamp of a u t h o r i t y . comment, on matters  He  s e t a standard of r e s p o n s i b l e and  of p u b l i c h e a l t h , which won  him much r e s p e c t .  He  impartial recognized  12  the v a l u e of v i t a l In 1855,  statistics.  r e f o r m of l o c a l government i n London allowed  f o r t y - e i g h t medical o f f i c e r s . thousand and  By 1857,  the Lancet  s a n i t a r y n u i s a n c e s had been removed.  the appointment of  c a l c u l a t e d upwards of  "They caught  fifteen-  a l l k i n d s of s t e n c h ,  snares and a l l s o r t s of n u i s a n c e . " However, i t was  were appointed 1875  not u n t i l 1872,  to 1400  by l e g i s l a t i o n ,  o t h e r areas i n the c o u n t r y .  marked the h i g h water mark of environmental  p l e t e system of h e a l t h .  Although  that Medical Health  Officers  The P u b l i c H e a l t h Act of  s a n i t a t i o n as a n a t i o n a l l y com-  c a r r i e d a l o n g by i t s own  momentum f o r many  y e a r s , towards the end of the c e n t u r y the s a n i t a r y i d e a began to be o v e r t a k e n a new  concept,  by  t h a t of the i n d i v i d u a l and h i s p e r s o n a l needs.  The g r e a t f e a t s o f s a n i t a t i o n had been accompanied by a s u b s t a n t i a l d e c l i n e i n the death r a t e and e s p e c i a l l y t h a t p a r t due  to i n f e c t i o u s d i s e a s e s .  M e d i c a l H e a l t h O f f i c e r had no time f o r complacency. remained o b s t i n a t e l y h i g h . enough and  The  The  infant mortality rate  I t became c l e a r t h a t environmental  c o n t r o l wasn't  t h a t s e r v i c e s d i r e c t e d towards the needs of v u l n e r a b l e groups were  necessary. By the b e g i n n i n g of t h i s c e n t u r y , a rudimentary welfare c l i n i c The  1902  s e r v i c e was  Midwives A c t l a i d  h e a l t h v i s i t i n g and  g r a d u a l l y b e i n g i n t r o d u c e d to improve i n f a n t the f o u n d a t i o n f o r the r e g u l a t i o n and  midwifery w i t h a view to r e d u c i n g m a t e r n a l m o r t a l i t y .  I t was  child care.  c o n t r o l of  not u n t i l  the  1930's t h a t the M a t e r n a l & C h i l d H e a l t h s e r v i c e s under the M e d i c a l H e a l t h reached  full  development.  G. Bernard 1903,  Officer  Shaw wrote to Sykes, M e d i c a l H e a l t h O f f i c e r f o r St. Pancras,  about concern f o r l a c k of involvement  of the M e d i c a l H e a l t h O f f i c e r i n  in  13  schools.  Sykes was a knowledgeable M e d i c a l H e a l t h O f f i c e r and had w r i t t e n  " S t a t e remedies cannot be a p p l i e d i n advance o f p u b l i c o p i n i o n , and t h i s i s slow to move. task to f a l l ally,  The e d u c a t i o n o f a v a s t community i s perhaps the most to sanitarians.  Persuading  t h e u n s c i e n t i f i c mind t o r e a s o n  even a f t e r p o s s e s s i o n o f the f a c t s ,  take a c t i o n , even when c o n v i n c e d , digious e f f o r t . "  Probably,  difficult  i s not a l i g h t task.  logic-  To rouse i t t o  and t o overcome p r e j u d i c e , r e q u i r e s a p r o -  t h i s i s a v e r y sound statement  on t h e d i f f i c u l t i e s  of h e a l t h e d u c a t i o n . Sykes responded t o Shaw w i t h a comprehensive j o b d e s c r i p t i o n f o r t h e M e d i c a l H e a l t h O f f i c e r i n s c h o o l s and encouraged M e d i c a l H e a l t h O f f i c e r s t o be i n v o l v e d i n examination troduced The  of school children.  The s c h o o l m e d i c a l  s e r v i c e was i n -  i n 1907. f i r s t World War h i g h l i g h t e d two grave  d i s e a s e and t u b e r c u l o s i s .  s i c k n e s s problems - v e n e r e a l  L e g i s l a t i o n and b r i s k o r g a n i z a t i o n f a c i l i t a t e d the  r a p i d development by p u b l i c h e a l t h departments o f v e n e r e a l d i s e a s e service.  clinic  A whole new s e r v i c e w i t h s t a f f and s a n i t o r i a beds was developed f o r  tuberculosis. immunization,  As knowledge o f i n f e c t i o u s d i s e a s e i n c r e a s e d so d i d n o t i f i c a t i o n , i s o l a t i o n and d i s i n f e c t i o n .  By the 1930's, the M e d i c a l H e a l t h O f f i c e r was i n c o n t r o l of a wide range of p e r s o n a l and environmental t i o n , d i a g n o s i s , treatment  h e a l t h s e r v i c e s c l o s e l y woven t o g e t h e r .  and r e h a b i l i t a t i o n - a l l came w i t h i n h i s compass but  p r e v e n t i o n was uppermost i n h i s mind. medicine  Preven-  (Wolfinden).  were put i n t o d a i l y p r a c t i c e - housing  The p r i n c i p l e s o f s o c i a l  and h e a l t h , s o c i a l w o r k and  t u b e r c u l o s i s , management o f handicapped c h i l d r e n i n s p e c i a l s c h o o l s , as w e l l as the p r e v i o u s l y mentioned development.  14  Following  t h e second World War new d u t i e s were added - p r o v i s i o n o f ambu-  lances, health centres,  home care and n u r s i n g ,  immunization r e s p o n s i b i l i t i e s . B r i t i s h Mental Health The  health education,  and i n c r e a s e d  Mental h e a l t h s e r v i c e s developed f o l l o w i n g the  A c t o f 1959.  U.K. S o c i a l S e r v i c e s A c t o f 1970 swallowed up mental h e a l t h s e r v i c e s ,  home h e l p ,  c h i l d r e n s work and s e r v i c e s f o r t h e c h i l d r e n and the aged.  The  c l e a v a g e i s p e r p e t u a t e d today. The  Medical  Health  O f f i c e r i n B r i t a i n , had a g r e a t  power and r e s p o n s i b i l i t y . While p u r p o r t i n g m e d i c i n e he was a g e n e r a l i s t . The Health  deal of l e g i s l a t i v e  t o be a s p e c i a l i s t i n p r e v e n t i v e  (Wolfinden 1974).  N.H.S., i n 1974, r e s u l t e d i n the d i s a p p e a r a n c e o f the c l a s s i c a l Medica]  Officer.  He and h i s h e i r s a r e now l a b e l l e d "community p h y s i c i a n s " -  some a r e employed i n a m e d i c a l a d m i n i s t r a t i v e c a p a c i t y a t r e g i o n a l , a r e a and district  l e v e l s but as members o f m u l t i p r o f e s s i o n a l teams.  m i o l o g i s t s and other m e d i c a l a d v i s o r s  of d i s t r i c t  h e a l t h m a t t e r s and s o c i a l and e d u c a t i o n a l The  Others a r e e p i d e -  c o u n c i l s on e n v i r o n m e n t a l  services.  i s s u e o f r o l e and i d e n t i t y , under t h i s new system, c o n t i n u e s  of the major problems t h a t f a c e s t h e s p e c i a l t y . seven hundred c o n s u l t a n t duty.  The other  role.  They should  grade posts  s i x - h u n d r e d should  t o be one  About one-hundred out o f t h e  i n the s p e c i a l t y have a major m a n a g e r i a l p l a y an a d v i s o r y  r a t h e r than an  executive  p r a c t i c e t h e a r t o f e p i d e m i o l o g y and c o n t r i b u t e towards t h e  s e t t i n g o f o b j e c t i v e s a t each l e v e l o f the s e r v i c e , measuring and e v a l u a t i n g need, demand and outcome.  Epidemiology and m e d i c a l s t a t i s t i c s should  b a s i c components o f community medicine. b u t e t o the h e a l t h o f p o p u l a t i o n  be the  Community m e d i c i n e s p e c i a l i s t s  groups i n a v e r y  d i r e c t way.  contri-  The f a c t t h a t the  15  e f f o r t s i n p r e v e n t i o n , p l a n n i n g and e v a l u a t i o n have not y e t r e c e i v e d the a t t e n t i o n they deserve can be a t t r i b u t e d l a r g e l y to d i f f i c u l t i e s a r i s i n g from r e o r g a n i z a t i o n and change o f r o l e . In c o n s i d e r i n g the new p u b l i c h e a l t h , M o r r i s l o o k s a t the e v o l u t i o n of the community  p h y s i c i a n as e p i d e m i o l o g i s t , a d m i n i s t r a t o r o f l o c a l m e d i c a l  community  c o u n s e l l o r , p r o f e s s i o n a l man  and p u b l i c s e r v a n t .  The  services,  traditional  t a s k s of the M e d i c a l H e a l t h O f f i c e r as t e a c h e r , watchdog, and troublemaker, i n h e a l t h , a r e b e i n g renewed and he w i l l have new d u t i e s i n the p r o v i s i o n of s e r v i c e s as an i n t e g r a l r e s o u r c e o f h e a l t h p r o t e c t i o n .  One o f h i s main t o o l s  be knowledge, a c o n t r i b u t i o n to s o c i a l p o l i c y a t every  level.  will  He w i l l be a b l e  to combine s o c i a l s c i e n c e and medicine. In 1906 the s o c i e t y of M e d i c a l H e a l t h O f f i c e r s b e l i e v e d t h a t the day of the M e d i c a l H e a l t h O f f i c e r would soon be over. the b e g i n n i n g . then and now  I t r e a l l y was o n l y the end of  A s i m i l a r i d e a s u r f a c e d i n the 1940's.  However, t h e r e  continued  to be new needs r e s u l t i n g i n an e v o l v i n g r o l e f o r the M e d i c a l  H e a l t h O f f i c e r and h i s c o n t i n u e d e x i s t e n c e under whatever t i t l e or l a b e l . C l e a r l y , t h e r e has never been consensus as to what the r o l e o f the M e d i c a l Health O f f i c e r i s i n B r i t a i n .  There has been c o n s t a n t r e - e v a l u a t i o n and r e -  o r g a n i z a t i o n o f the j o b d e s c r i p t i o n . E d u c a t i o n of the M e d i c a l H e a l t h O f f i c e r i n U.K. T h i s c o n f u s i o n has been engendered i n t o the e d u c a t i o n a l p r o c e s s as w e l l . The o r i g i n a l M e d i c a l H e a l t h O f f i c e r s i n the U.K. were simply q u a l i f i e d p h y s i c i a n s , but as the f i e l d The f i r s t  progressed  Diploma i n P u b l i c H e a l t h  a need f o r e x t r a t r a i n i n g was  recognized.  (D.P.H.) began i n D u b l i n i n 1871 f o l l o w e d by  16  & Cambridge i n 1875.  I n 1888 a M e d i c a l H e a l t h O f f i c e r s u r v e y i n g a p o p u l a t i o n  g r e a t e r than f i f t y - t h o u s a n d p o p u l a t i o n was r e q u i r e d to have the D.P.H. c a t i o n , which took about a year to o b t a i n . H e a l t h O f f i c e r had t o be so q u a l i f i e d .  By 1922 i n B r i t a i n , every  qualifiMedical  The q u a l i f i c a t i o n c o n t a i n e d as much o f  the v a r i o u s elements r e q u i r e d i n p u b l i c h e a l t h p r a c t i c e and a d m i n i s t r a t i o n as c o u l d be f i t i n t o a one year p e r i o d . Community medicine  matter i s c o n t i n u o u s l y changing.  As w i t h any o t h e r d i s c i p l i n e the s u b j e c t A d o c t o r p l a n n i n g a c a r e e r i n community medi-  c i n e should o b t a i n a v a r i e d c l i n i c a l  had  e x p e r i e n c e , p r e f e r a b l y both i n h o s p i t a l  i n general p r a c t i c e , before s t a r t i n g s p e c i f i c t r a i n i n g .  flexibility  changed.  r e p r e s e n t s a p r o g r e s s i v e combined development o f m e d i c a l  a d m i n i s t r a t i o n and p u b l i c h e a l t h .  and  The course o f the r o l e  T h i s method  i n e a r l y t r a i n i n g i n case t r a i n e e s should f e e l t h a t t h e s p e c i a l t y  l e s s o f an appeal  than f e l t  initially.  The Lancet d i s a g r e e s w i t h Heath & P e r r y ' s emphasis on f u l l at  retains  a u n i v e r s i t y course.  time  attendance  Many d o c t o r s t r a i n i n g f o r o t h e r s p e c i a l t i e s have t o  combine the s e r v i c e and academic a s p e c t s o f the j o b , and indeed  separation of  these i s one o f the major c r i t i c i s m s t h a t has been l e v e l l e d a g a i n s t community medicine  i n the past.  The Lancet  t i o n o f a s u b s p e c i a l i s t grade. to  epidemiology  a l s o disagrees with t h e i r suggestion of c r e a -  The Lancet  can community medicine  t h i s d i s c i p l i n e can r e v e a l the impact  felt  t h a t o n l y by g i v i n g proper  a t t r a c t t h e b e s t young minds, and o n l y o f the s p e c i a l t y on h e a l t h .  Tomorrow's community p h y s i c i a n i n the U.K. w i l l l o c a l h e a l t h s e r v i c e s but can o n l y succeed system.  L o c a l epidemiology  place  continue to administer  by b u i l d i n g an e f f e c t i v e  should be the frame f o r c l i n i c a l  intelligence  p r a c t i c e and team-  work, p r o v i d e t o o l s f o r management and improvement o f s e r v i c e s and more a n a l y s i s  17  and  trials.  A f t e r twenty y e a r s one  of the sadder d i s a p p o i n t m e n t s of the N.H.S.  i s the p o v e r t y a t the l o c a l l e v e l of i t s l e a r n i n g r e s o u r c e s . t h e r e can be no The  planning  to " r e a l i z e an image of the f u t u r e " - no  unique c o n t r i b u t i o n of the community p h y s i c i a n , and  n i t y l e a d e r s h i p , w i l l be  the i n f o r m a t i o n  Times have changed and b a l a n c e of r e s o u r c e s  and  complexities  i t was  system he  In order  the more i n t e n s e and and  to p r e s e r v e a h o s p i t a l care,  dramatic of the  two  h i g h l y t r a i n e d d o c t o r who  a knowledge o f both f u n c t i o n a l p a r t s , i s r e q u i r e d T  He would be a m e d i c a l  t i t i o n e r e i t h e r w i t h e x p e r i e n c e i n primary c a r e or h o s p i t a l s who undertaken an MSc  to commu-  creates.  increased.  suggested t h a t a d i p l o m a t i c  rationality.  h i s passport  s e r v i c e a l l o c a t i o n between community and  when the l a t t e r i s o f t e n s a i d to be functions,  Without knowledge  prac-  subsequently  sociology.  Such  a person would have a s t a k e i n the f u t u r e h e a l t h s e r v i c e a d m i n i s t r a t i o n ,  which  must c o v e r and  and  co-ordinate  or f e l l o w s h i p i n m e d i c a l a d m i n i s t r a t i o n and  had  has  b a l a n c e the whole spectrum o f h o s p i t a l and  the f i e l d m u l t i - d i s c i p l i n a r y teams.  combined d i s c i p l i n e .  His  would l i k e l y enable him care,  as c o - o r d i n a t o r  Now, right. and  He would be p o s s e s s o r o f a  apprenticeship  and  facilitator.  other,  other  "caring" professions  physiotherapists  still  g e n e r a l l y d e a l w i t h more l i m i -  as a s p e c i a l t y i n i t s  been continuous reassessment, r e - e v a l u a t i o n ,  change i n the e d u c a t i o n a l  process.  In t r a i n i n g the M e d i c a l  O f f i c e r has  own  reorganization, Health O f f i c e r  the obvious l a c k of consensus i n the o r g a n i z a t i o n of p u b l i c h e a l t h and Health  such as  behaviour.  a t l e a s t community m e d i c i n e i s r e c o g n i z e d  of the M e d i c a l  patient  The  s p e c i a l i z e d areas of human f u n c t i o n and  There has  more than any  to encompass the whole spectrum of community and  n u r s e s , s o c i a l workers and ted and  t r a i n i n g and  community c a r e  been c a r r i e d i n t o the e d u c a t i o n a l  the r o l e  model.  18  b. U n i t e d  States  In the U n i t e d S t a t e s t h i s c o n f u s i o n has been c a r r i e d a s t e p f u r t h e r . amination  of the r o l e of the Medical Health O f f i c e r  Ex-  (Miller & Albers) indicates  t h a t r e g i s t e r e d nurses w i t h a masters degree i n p u b l i c h e a l t h i n many cases have more t r a i n i n g and e x p e r i e n c e this role.  I t i s suggested  than p h y s i c i a n s t o f u n c t i o n e f f e c t i v e l y i n  t h a t , g i v e n c u r r e n t p h y s i c i a n s h o r t a g e s , t h e change  i n scope o f p u b l i c h e a l t h p r a c t i c e , and the use o f o t h e r p r o f e s s i o n a l s c a p a b l e of f u l f i l l i n g  t h i s r o l e , t h e s e l e c t i o n o f p h y s i c i a n s as l o c a l h e a l t h o f f i c e r s  should be viewed as o n l y one o f s e v e r a l a l t e r n a t i v e s . The  e a r l i e s t documented i n s t a n c e o f t h e use o f a non-medical person as a  l o c a l h e a l t h o f f i c e r o c c u r r e d i n 1873 i n New J e r s e y .  A recent unpublished  sur-  vey o f c u r r e n t p r a c t i c e s among s t a t e s , w i t h r e g a r d t o the use o f n o n - p h y s i c i a n s as M e d i c a l H e a l t h O f f i c e r s i n d i c a t e s t h a t t w e n t y - f i v e s t a t e s now use such sonnel, while twenty-five states s t i l l H e a l t h O f f i c e r be a l i c e n c e d p h y s i c i a n .  per-  r e q u i r e by law o r p o l i c y t h a t a M e d i c a l The i n a b i l i t y o f many communities to  r e c r u i t p h y s i c i a n s t o f i l l M e d i c a l H e a l t h O f f i c e r p o s i t i o n s i s an obvious s t i mulus toward the use o f other q u a l i f i e d  personnel.  E d u c a t i o n o f the M e d i c a l H e a l t h O f f i c e r i n the U n i t e d  States  N e a r l y t w o - t h i r d s o f a l l h e a l t h o f f i c e r s i n t h e U n i t e d S t a t e s have an M.P.H. ( o r s i m i l a r ) degree.  About 23% have b o t h an M.D. and M.P.H. (or s i m i l a r )  degree; about 9% have a b a c h e l o r degree, o r no degree a t a l l . The h i g h e s t p r o p o r t i o n o f h e a l t h o f f i c e r s who a r e p h y s i c i a n s i s found i n the P a c i f i c and South A t l a n t i c r e g i o n s  (96.6% and 88.2% r e s p e c t i v e l y ) .  about 25% o f h e a l t h o f f i c e r s i n t h e Mid A t l a n t i c and New England physicians.  About o n e - h a l f o f t h e h e a l t h o f f i c e r s  Only  regions are  i n the South A t l a n t i c and  19  P a c i f i c r e g i o n s have M.P.H. or s i m i l a r degrees. The  growth and  development of s t a t e and  l a r g e l y upon the knowledge, s k i l l s and Public Health Administrators  should  l o c a l h e a l t h agencies w i l l  a t t i t u d e s of t h e i r p r o f e s s i o n a l  inform schools  F a c u l t y members should  have a r e s p o n s i b i l i t y  encourage t h i s .  centered  l i n e s should  a t t i t u d e s they want  Schools of p u b l i c h e a l t h  to be among the l e a d e r s i n d e v e l o p i n g  p a t t e r n s of program changes i n community h e a l t h . recognize  a t t i t u d e s towards  Course content  social  Health  Officer  deep u n d e r s t a n d i n g of human n a t u r e as w e l l as f o r m a l the h e a l t h s c i e n c e s . It's  problem  specialists in  sciences.  In p e r f o r m i n g h i s d u t i e s , the M e d i c a l  and  along  t h a t a d m i n i s t r a t i v e o r g a n i z a t i o n and management  i n community h e a l t h r e q u i r e the j o i n t e f f o r t s of g e n e r a l i s t s and the m e d i c a l and  5>  staffs  of p u b l i c h e a l t h about what  knowledge they want t r a i n e e s to a c q u i r e and what s k i l l s and developed.  depend  Leadership  important t h a t M e d i c a l  ( p h y s i c i a n ) needs a  training i n administration  ability is essential.  Health  O f f i c e r s have a broad e d u c a t i o n a l  ground as w e l l as t r a i n i n g i n m e d i c i n e and  public health.  programs are a v a i l a b l e to t r a i n a competent s p e c i a l i s t  A v a r i e t y of advanced  in this field.  Recog-  n i t i o n of t h i s competence through c e r t i f i c a t i o n by the American Board of ventive Medicine i s d e s i r a b l e . or p r e v e n t i v e m e d i c i n e , to reach ward c o n t i n u i n g e d u c a t i o n  Residency t r a i n i n g and t h i s end,  Pre-  a degree i n p u b l i c h e a l t h  i s suggested.  throughout the l i f e  back-  A sustained  effort  to-  of the p r o f e s s i o n a l i s a l s o essen-  tial. The  d i v e r i s t y and  number of o c c u p a t i o n a l  of s c h o o l s of p u b l i c h e a l t h i s so g r e a t  titles  t h a t no  i n which we  find  graduates  s i n g l e - c o r e c u r r i c u l u m can hope  to prepare i n d i v i d u a l s a d e q u a t e l y f o r p r a c t i c e i n the f i e l d .  Public Health  en-  20  compasses d i r e c t m e d i c a l c a r e , the s e t t i n g of standards f o r c l i n i c a l and titutional  ins-  p r a c t i c e , the o r g a n i z a t i o n and a d m i n i s t r a t i o n of a v a r i e t y of commu-  n i t y h e a l t h programs and a m u l t i t u d e of o t h e r programs. s e t t i n g f o r the p r a c t i c e of p u b l i c h e a l t h has Kinney  proposes  p l i n e concerned  At the same time  the  changed.  r e d e f i n i n g p u b l i c h e a l t h i n the U n i t e d S t a t e s as a d i s c i -  w i t h adequate f u n c t i o n i n g of the i n d i v i d u a l i n the p o l i t i c a l ,  s o c i a l and p h y s i c a l environment i n which c o n d i t i o n s p l a c e him a t a p o i n t i n time.  To him  i t i s a matter  t h a t p u b l i c h e a l t h tends c i n e and  the h o s p i t a l .  of a p p l i e d "human e c o l o g y . "  Brotherston stated  to be d e t a t c h e d from the mainstream of c l i n i c a l mediCommunity medicine  s h o u l d a c t as a c e n t r a l f o c a l p o i n t  <*3> for  the growth of "human e c o l o g y . " M e d i c a l H e a l t h O f f i c e r s i n the U n i t e d S t a t e s today a r e more l i k e l y  themselves  i n v o l v e d i n p o l i t i c a l m a n i p u l a t i o n than b i o s t a t i s t i c a l  more l i k e l y  to be c a l l e d  s o l i d wastes; and  to e x e r c i s e t h e i r knowledge of s o l i d  f a r more l i k e l y  to f i n d  manipulation;  l o g i c than of  to be c o n f r o n t e d by the problem of the e p i -  demiology of d i s s e n t than of d i p h t h e r i a . A unique experience.  f e a t u r e among s t u d e n t s i n p u b l i c h e a l t h programs i s m a t u r i t y Kinney  and  f e e l s t h a t few of the s c h o o l s take advantage of the oppor-  t u n i t y to have these s t u d e n t s w i t h s p e c i a l i z e d s k i l l s p a r t i c i p a t e i n the p r o gram r a t h e r t h a t s i t as p a s s i v e r e c i p i e n t s . l e a r n , where the r e a l w o r l d of e x p e r i e n c e and i n such a way  Students  the w o r l d of t h e o r y can  as t o produce deeper u n d e r s t a n d i n g  h e a l t h p h i l o s o p h y based  s h o u l d teach as w e l l as  on i n d i v i d u a l d i g n i t y and  interact  and g r e a t e r commitment t o a s o c i e t a l good.  21  H i s f i n a l recommendations s t r e s s c e a s i n g t o educate n i n e month wonders "pseudo - e p i d e m i o l o g i c - b i o s t a t i s t i o - environmento - a d m i n i s t r a t o l o g i s t s " and  t o c o n c e n t r a t e on the masters l e v e l s t u d e n t s on an e c o l o g i c a l p e r s p e c t i v e  and a p h i l o s o p h i c a l base f o r the p r a c t i c e o f p u b l i c h e a l t h . restricted  t o make maximum use o f student  community i n t o the s c h o o l through  e x p e r i e n c e and s k i l l s .  B r i n g the  e n t r y l e v e l t r a i n i n g and c a r e e r l a d d e r  grams i n the v a r i o u s p u b l i c h e a l t h content Finally,  C u r r i c u l a should be  areas.  (Mytinger, R.E.) emphasized the importance o f attempting  c r u i t r e c e n t , w e l l q u a l i f i e d graduates  pro-  to r e -  i n t o p u b l i c h e a l t h and o f p r o v i d i n g them  w i t h o p p o r t u n i t i e s f o r advanced p u b l i c h e a l t h t r a i n i n g .  He found,  i n a study,  that the b e s t g e n e r a l p r e d i c t o r s o f a t t i t u d e s r e l a t e d t o i n n o v a t i v e n e s s were rank i n m e d i c a l  s c h o o l g r a d u a t i n g c l a s s and degrees h e l d beyond the b a c h e l o r  level. In the U n i t e d S t a t e s the extent o f d i v e r s i f i c a t i o n i n d e f i n i n g t h e M e d i c a l H e a l t h O f f i c e r common r o l e has been c a r r i e d beyond the p h y s i c i a n who t r a d i t i o n a l l y has f i l l e d  the r o l e .  They i n c l u d e o t h e r r e l a t e d p r o f e s s i o n a l s .  a t i o n a l process  i s more confused  The educ-  a g a i n and admits i t s l i m i t a t i o n i n p r e p a r i n g  the i n d i v i d u a l f o r the f i e l d and an i n a b i l i t y  t o develop  a core curriculum.  There i s n ' t a h i n t o f consensus on the r o l e o f the M e d i c a l H e a l t h O f f i c e r i n the U n i t e d S t a t e s which extends t o i n d e c i s i o n on who he should be. c. Canada The  term M e d i c a l H e a l t h O f f i c e r s t i l l  o b l i t e r a t e d by change as i n B r i t a i n .  e x i s t s i n Canada and has n o t been  Attempting  t o p r e d i c t the r o l e o f the  M e d i c a l H e a l t h O f f i c e r might be d e s c r i b e d e i t h e r as p e e r i n g a t a v e r y murky c r y stal ball,  or perhaps b e t t e r l o o k i n g a t a k a l e i d o s c o p e which never s t o p s t u r n i n g  22  and  produces an ever changing  simple matter i t used to be, (lifestyle)  picture.  P r e v e n t i o n i s f a r from the  e i t h e r primary  i s a v e r y d i f f i c u l t area indeed.  or secondary.  relatively  Changing  behaviour  Unfortunately, there are very  few  w e l l - p r o v e n methods o f h e a l t h e d u c a t i o n which can be r e a d i l y and i n e x p e n s i v e l y a p p l i e d i n the community. Schwenger envisages I.  two main r o l e s :  The M e d i c a l H e a l t h O f f i c e r can c o n c e n t r a t e on the r o l e d e s c r i b e d by Morris.  T h i s should s a t i s f y the more m e d i c a l l y o r i e n t e d M e d i c a l  H e a l t h O f f i c e r who and  statistical  as a s s e s s o r  w i l l have a d d i t i o n a l c l i n i c a l , e p i d e m i o l o g i c a l  training.  T h i s r o l e has been d e s c r i b e d  (watchdog), monitor  (troublemaker),  essentially  and c o u n s e l l o r  (teacher) or, II.  The M e d i c a l H e a l t h O f f i c e r can c o n c e n t r a t e on the c o - o r d i n a t i o n o f h e a l t h s e r v i c e s or even c o - o r d i n a t i o n of h e a l t h and He  feels i t i s unrealistic  do both j o b s . and  Macintosh  services.  the M e d i c a l H e a l t h O f f i c e r  More M.D.'s w i l l be f i l l i n g  a s m a l l e r number w i l l  their liking.  to expect  social  to  the job of community d o c t o r  f i n d the t a s k of s e n i o r a d m i n i s t r a t o r to  M e d i c a l s c h o o l s should be prepared  to t r a i n both  types.  s t a t e s " M e d i c a l H e a l t h O f f i c e r s do not have a d e f i n e d r o l e .  They do not have one  g e n e r a l f u n c t i o n which i s r e c o g n i z e d by a l l , both w i t h i n  the corps of M e d i c a l H e a l t h O f f i c e r s , w i t h i n the ranks of the m e d i c a l p r o f e s s ion,  by t h e i r employees and by the p u b l i c a t l a r g e , as the f u n c t i o n a t which  they should aim goal."  to be good.  T h e r e f o r e they have no r e c o g n i z a b l e o c c u p a t i o n a l  He a l s o sees a g r a d u a l f a d i n g away of the M e d i c a l H e a l t h O f f i c e r as  obsolescent species.  an  23  Education  of M e d i c a l  Health  In a 1960  questionnaire  O f f i c e r s In Canada  study c o n c e r n i n g  r e v i s i o n of the D.P.H. course i n (St)  Toronto, Le R i c h e c o n t r a s t e d  s e v e r a l hundred p u b l i c h e a l t h p r o g r a m s ? ^ -  He a l s o found out what Toronto graduates thought of the c u r r i c u l u m D.P.H. and  brought about c o n s i d e r a b l e  optional subjects.  A D.P.H. r e v i s i o n committee was  instituted  i n 1969  There was  and  i n the D.P.H. or to move towards an American type  In 1975,  being  of e x i s t i n g l o c a l h e a l t h a g e n c i e s would no  The  the posts would be open to c o m p e t i t i o n  l e a d e r s h i p and  perogative  f o r the  profess-  charisma, not  ex-  alone.  top l e v e l of q u a l i f i c a t i o n i n Canada i s the F.R.C.P. i n p u b l i c h e a l t h ,  hundred and  In 1972,  t h i r t y - t h r e e of these s p e c i a l i s t s ,  However, 48%  ination  Administration  among managers hav-  Teamwork would i n c l u d e r e s p e c t  or more r e c e n t l y i n community m e d i c i n e .  B.C.  transformed  l o n g e r be the e x c l u s i v e  i o n a l autonomy of f e l l o w h e a l t h workers w i t h e l u s i v e to the M.D.  include  all-purpose  to be  i n t o an M.P.H. which would be open to a l l h e a l t h p r o f e s s i o n a l s .  i n g a v a r i e t y of backgrounds.  to  crammed i n t o a n i n e months course?  however, Schwenger s t a t e s t h a t the D.P.H. was  of the p h y s i c i a n but  ex-  some d i f f i -  c u l t y i n a r r i v i n g at consensus on f u t u r e changes, i . e . , whether or not  M.P.HT"^ Perhaps too much was  the  changes i n c l u d i n g the i n t r o d u c t i o n of  changed views on the f u t u r e r o l e of the D.P.H. course.  non-physicians  for  of a l l s p e c i a l i s t s who  (not honorary) were i n B.C.  had  Anderson found t h a t of  38% were i n O n t a r i o , and obtained  C e r t i f i c a t i o n was  of the F.R.C.P.  29%  in  the c e r t i f i c a t e by examc l e a r l y r e l a t e d to c a r -  eer development i n t h a t s i n g l e p r o v i n c e where s a l a r y d i f f e r e n t i a l s and f a v o r the h o l d e r  one-  Elsewhere, the c e r t i f i c a t e was  promotion  regarded merely  24  as a mark o f e x c e l l e n c e or c l i n i c a l  competence.  T h i s s i t u a t i o n remains  simi-  l a r today i n B.C. The  s p e c i a l t y t r a i n i n g requirements  s e t out by t h e R o y a l C o l l e g e o f P h y s i -  c i a n s and Surgeons o f Canada (February 1978) f o r community m e d i c i n e p h y s i c i a n must have a b a s i c knowledge o f epidemiology w e l l as an a p p r o p r i a t e u n d e r s t a n d i n g and o f a d m i n i s t r a t i o n .  s t a t e the  and b i o s t a t i s t i c s , as  o f the p r i n c i p l e s o f the s o c i a l sciences  The c a n d i d a t e i s expected  t o develop  a field  o f concen-  t r a t i o n from one o f t h e s e f i v e a r e a s : p u b l i c h e a l t h , a d m i n i s t r a t i o n of h e a l t h s e r v i c e s , maternal cine.  and c h i l d h e a l t h , epidemiology  o r c l i n i c a l p r e v e n t i v e medi-  There a r e s e t out two streams o f t r a i n i n g requirements  of four years  each t o r e a c h t h i s end. The U n i v e r s i t y o f B r i t i s h Columbia o f f e r s an MSc ( h e a l t h s e r v i c e s p l a n n i n g ) which f u l f i l l s cians.  the above requirements,  i n i t s public health option, f o r physi-  The program i s i n t e r d i s c i p l i n a r y  i n approach and may be a good  indica-  t i o n o f where e d u c a t i o n o f the M e d i c a l H e a l t h O f f i c e r i n Canada i s going but t h e r e i s some u n c e r t a i n t y among t h e l e a d e r s as t o whether t h i s type o f t r a i n i n g i s the d e s i r a b l e route f o r the Medical Health O f f i c e r .  There a r e a v a r i e t y o f  r o u t e s one can pursue t o become F.R.CP. e l i g i b l e , i n c l u d i n g c r e d i t f o r a year i n "any" dency.  clinical  s p e c i a l t y or c r e d i t  These numerous combinations  f o r two y e a r s i n a f a m i l y p r a c t i c e  of training c e r t a i n l y i l l u s t r a t e a lack of  agreement on a common t r a i n i n g r o u t e f o r t h e M e d i c a l H e a l t h The  situation  resi-  Officer.  i n Canada, i n g e n e r a l , i s perhaps o n l y s l i g h t l y l e s s  i n g than t h a t i n the U n i t e d S t a t e s on t h e r o l e o f t h e M e d i c a l H e a l t h  Officer.  5. P r o v i n c i a l V a r i a t i o n s i n P u b l i c H e a l t h and M e d i c a l H e a l t h O f f i c e r We can now examine the major r e g i o n s o f Canada, a t t e m p t i n g  confus-  Roles  t o f i n d a common  25  denominator.  A l e t t e r was  w r i t t e n to the o t h e r p r o v i n c e s , b e s i d e s B.C.,  to r e -  view p u b l i c h e a l t h o r g a n i z a t i o n and M e d i c a l H e a l t h O f f i c e r d e s c r i p t i o n s a c r o s s the c o u n t r y .  There was  and Nova S c o t i a , and  response  from a l l a r e a s , except P r i n c e Edward I s l a n d  these are summarized here where i n f o r m a t i o n was  Newfoundland employs one  f u l l - t i m e Medical Health O f f i c e r .  given.  A second  Medi-  c a l H e a l t h O f f i c e r i s employed by the I n t e r n a t i o n a l G r e n f e l l A s s o c i a t i o n to l o o k a f t e r p u b l i c h e a l t h programs i n Newfoundland and  coastal  Labrador.  P u b l i c h e a l t h programs are a d m i n i s t e r e d c e n t r a l l y from St. Johns and  the  M e d i c a l H e a l t h O f f i c e r i s o c c u p i e d w i t h a d m i n i s t r a t i o n of the p r o v i n c i a l immun i z a t i o n program, communicable d i s e a s e c o n t r o l and epidemiology.  M e d i c a l sup-  p o r t i s p r o v i d e d by the M e d i c a l H e a l t h O f f i c e r to p u b l i c h e a l t h n u r s e s , h e a l t h i n s p e c t o r s and  the d i v i s i o n of N u t r i t i o n and H e a l t h E d u c a t i o n throughout  the  province. A l s o employed are f o u r f u l l - t i m e C h i l d H e a l t h O f f i c e r s , p e d i a t r i c q u a l i f i c a t i o n s or experience). c e n t r a l Newfoundland and one  i n the west.  Two  (physicians with  are l o c a t e d i n S t . Johns, one i n  They are o c c u p i e d m a i n l y w i t h p r e -  s c h o o l and s c h o o l h e a l t h assessments and w i t h p r o v i d i n g support nurses  to p u b l i c h e a l t h  i n these a r e a s .  The p r o v i n c i a l o b j e c t i v e i s to o r g a n i z e f o u r h e a l t h r e g i o n s and each w i t h a M e d i c a l H e a l t h O f f i c e r ,  to s t a f f  Child Health O f f i c e r , N u t r i t i o n i s t  and  Health  E d u c a t i o n person.  Emphasis would be p l a c e d on immunization,  h e a l t h promotion.  The M e d i c a l H e a l t h O f f i c e r would be r e s p o n s i b l e f o r i n f o r -  mation systems f o r h i s r e g i o n and New  Brunswick has  c h i l d h e a l t h and  f o r p l a n n i n g programs to meet the needs  f i v e r e g i o n a l h e a l t h d i s t r i c t s d i r e c t e d by M e d i c a l H e a l t h  O f f i c e r s employed by the p r o v i n c e .  No  d i s c u s s i o n of the r o l e of the M e d i c a l  26  Health  O f f i c e r was a v a i l a b l e but program a c t i v i t i e s o f t h e u n i t s i n c l u d e d mat-  e r n a l & c h i l d h e a l t h , communicable d i s e a s e  c o n t r o l , p u b l i c h e a l t h n u r s i n g and  i n s p e c t i o n , home c a r e , n u t r i t i o n , l o n g term c a r e , o c c u p a t i o n a l education,  therapy, h e a l t h  r a d i a t i o n and T.B. c o n t r o l .  There was no i n f o r m a t i o n the p r o c e s s  from P r i n c e Edward I s l a n d but t h i s p r o v i n c e  o f revamping i t s H e a l t h  is in  Care System p l a c i n g t h e r e s p o n s i b i l i t y o f  h e a l t h c a r e on the p u b l i c as w e l l as h e a l t h p r o f e s s i o n a l s and p h y s i c i a n s . emphasis w i l l be on h e a l t h promotion and i l l n e s s p r e v e n t i o n  and h e a l t h  The  education  to encourage i n d i v i d u a l s t o take more r e s p o n s i b i l i t y f o r t h e i r h e a l t h .  This i s  i n t h e form o f an experiment as l a i d out i n a " D i s c u s s i o n Paper" and would obviously result  i n a magnified  r o l e f o r the community p h y s i c i a n ,  (Medical  Health  O f f i c e r ) i f implemented. Quebec sent a s u b s t a n t i a l document, i n French. developed i n tune w i t h public health with vices,  I n 1973 t h i s document was  t h e Castonguay Report recommending t h e i n t e g r a t i o n o f  the g e n e r a l regime o f d i s t r i b u t i o n o f h e a l t h and s o c i a l  i n c l u d i n g h o s p i t a l s and community h e a l t h c e n t r e s .  p u b l i c h e a l t h was s u f f e r i n g under two s e p a r a t e h o s p i t a l care. t h i n g should  Also, with  that  regimes o f community care and  t h e development o f community h e a l t h c e n t r e s t h e whole  be p u l l e d t o g e t h e r .  i n 12 r e g i o n a l d i s t r i c t s .  I t was f e l t  ser-  The p l a n would be implemented i n 31 h o s p i t a l s  I t was decided  to enlarge  h o s p i t a l s t o house t h e d i v i s i o n o f community h e a l t h .  r e s p o n s i b i l i t i e s o f the T h i s department would  p l a y a major r o l e i n the c o - o r d i n a t i o n o f h e a l t h and s o c i a l s e r v i c e s i n commun i t y h e a l t h c e n t r e s , h o s p i t a l s and p u b l i c h e a l t h , thus b r i n g i n g t o g e t h e r a l l areas of prevention  and treatment.  In p r e v i o u s  a l l o c a t i o n t o p u b l i c h e a l t h had s u f f e r e d .  years, with  separation,  resource  27  The  department of community h e a l t h housed i n the h o s p i t a l s would be  p o n s i b l e f o r the development of p r e v e n t i v e  s e r v i c e s f o r the l o c a l  res-  community  h e a l t h c e n t r e s , f o r development of p h y s i c i a n and mental h e a l t h programs r e f l e c t i n g the needs of the p a r t i c u l a r p o p u l a t i o n , and  to p a r t i c i p a t e i n h e a l t h s t u d i e s and  the h o s p i t a l and The  c o n t r o l of a c c i d e n t s and  to c o u n s e l  epidemics  the board of d i r e c t o r s of  r e g i o n on h e a l t h m a t t e r s .  community h e a l t h d i v i s i o n would be under the d i r e c t i o n of a p h y s i c i a n  (Medical Health  O f f i c e r ) t r a i n e d i n m e d i c i n e , epidemiology and  administration.  I t would be d e s i r a b l e t h a t the department of community h e a l t h would be i a t e d w i t h a department of s o c i a l and  affili-  p r e v e n t i v e m e d i c i n e of a u n i v e r s i t y .  The  M e d i c a l H e a l t h O f f i c e r would be r e s p o n s i b l e f o r the programs mentioned i n the previous  paragraph and  v e n t i v e and has  l e a d e r s h i p i n c o - o r d i n a t i n g and  c u r a t i v e h e a l t h needs of the community.  administering  the  pre-  T h i s i s the r o u t e Quebec  been f o l l o w i n g The  Officer.  province No  of O n t a r i o  sent  some g u i d e l i n e s r e s p e c t i n g the M e d i c a l  d e t a i l s on j o b d e s c r i p t i o n were a v a i l a b l e .  s t a t e d the f u n c t i o n of the M e d i c a l the Board of H e a l t h .  He  Health  In g e n e r a l  O f f i c e r as the e x e c u t i v e  i s r e s p o n s i b l e f o r promotion and  Health  terms, they officer  p r o t e c t i o n of  of  the  h e a l t h of the p u b l i c , f o r keeping the board informed on h e a l t h s u b j e c t s , f o r implementing p o l i c i e s and  d i r e c t i v e s of the board and  f o r e f f e c t i v e management  (3) of h e a l t h u n i t or h e a l t h department  activities.  Amalgamation of the departments of H e a l t h i n 1970.  When t h i s happened, the M e d i c a l  health consultant The  province  and W e l f a r e o c c u r r e d  i n Manitoba,  H e a l t h O f f i c e r became a m e d i c a l p u b l i c  to the p u b l i c h e a l t h nurses,  s o c i a l workers and  i s d i v i d e d i n t o eight regions with  other  staff.  a regional director i n  28  charge and the M e d i c a l  Health  O f f i c e r i s no l o n g e r  the u n i t s b u t a c t s as a c o n s u l t a n t w i t h r i p t i o n , he i s d e s c r i b e d  chief executive  some d i r e c t d u t i e s .  as a m e d i c a l r e s o u r c e  o f f i c e r of  In h i s r o l e desc-  t o the r e g i o n and c o n s u l t a n t i n  p u b l i c h e a l t h and h e a l t h c a r e , p a r t i c i p a t i n g as a member o f the r e g i o n a l management e x e c u t i v e  group.  l i v e r y and m o n i t o r i n g nity.  He i s t o p l a y an a c t i v e r e s o u r c e  r o l e i n p l a n n i n g , de-  o f community h e a l t h programs o f the department and commu-  He w i l l r e p o r t t o a r e g i o n a l d i r e c t o r on a day t o day b a s i s but w i l l be  r e s p o n s i b l e and a c c o u n t a b l e f o r program standards and p r o f e s s i o n a l competence to the e x e c u t i v e  d i r e c t o r of P u b l i c Health  Services.  Under g e n e r a l and s p e c i f i c  r e s p o n s i b l i t i e s t h e r e a r e 27 p o i n t s l i s t e d which cover v i r t u a l l y every of community medicine and which s t r e s s the c o n s u l t a n t r a t h e r than any a d m i n i s t r a t i v e t a s k s . of the r e g i o n a l d i r e c t o r .  and d i r e c t  area  services role  These appear t o be the r e s p o n s i b i l i t y  Quebec, A l b e r t a and Manitoba have i n c l u d e d mental  h e a l t h and s o c i a l s e r v i c e s i n t h e i r community m e d i c i n e programs. Saskatchewan has a d e c e n t r a l i z e d d e l i v e r y system f o r p u b l i c h e a l t h grams whereby the p r o v i n c e Medical  Health  i s divided into ten regions,  each w i t h  O f f i c e r and s t a f f o f h e a l t h p r o f e s s i o n a l s .  i t s own  Local participation  i s encouraged through r e g i o n a l h e a l t h boards which a r e a d v i s o r y of H e a l t h .  pro-  t o the M i n i s t r y  Regina, Saskatoon and the North have autonomous h e a l t h programs r e -  l y i n g h e a v i l y on p r o v i n c i a l s t a n d a r d s . They have had some problems i n r e c r u i t i n g p h y s i c i a n s Health  Officer positions.  to f i l l  the M e d i c a l  No r o l e d e s c r i p t i o n s were a v a i l a b l e but the p o s i t i o n  here i s a g a i n a combination o f a d m i n i s t r a t i v e and d i r e c t s e r v i c e f u n c t i o n s . There have been s e v e r a l a d m i n i s t r a t i v e s t u d i e s done i n t e r n a l l y t o t r y t o improve the d e l i v e r y system f o r p u b l i c h e a l t h programs.  29  A l b e r t a e n c l o s e d a working paper on j o b d e s c r i p t i o n s f o r H e d i c a l H e a l t h O f f i c e r s and a p o s i t i o n paper on the f u t u r e of the M e d i c a l H e a l t h O f f i c e r i n A l b e r t a as a community p h y s i c i a n .  I t was  s t r e s s e d t h a t the A l b e r t a M e d i c a l  H e a l t h O f f i c e r s were opposed to many p a r t s of the papersT ^ -  Dr.  Schnee,an A l b e r t a p u b l i c h e a l t h p h y s i c i a n , s u b m i t t e d p o l i c y papers to  s e r v e as a f o c u s f o r d i s c u s s i o n s between the d i v i s i o n of l o c a l h e a l t h s e r v i c e s and h e a l t h u n i t s , w i t h the o b j e c t of j o i n t l y e s t a b l i s h i n g a p o l i c y f o r the f u t u r e r o l e of M e d i c a l H e a l t h O f f i c e r s i n A l b e r t a . He  felt  lifestyle  t h a t new  c h a l l e n g e s had  emerged i n p u b l i c h e a l t h , c h r o n i c and  d i s e a s e s , the aged, a l t e r n a t i v e s to h i g h i n s t i t u t i o n a l c o s t s and  co-  o r d i n a t i o n of the m u l t i p l i c i t y of h e a l t h and h e a l t h r e l a t e d s o c i a l s e r v i c e s i n the community. water, and  These have r e p l a c e d emphasis on communicable d i s e a s e s , food  s a n i t a t i o n and maternal  and  & c h i l d h e a l t h which are under b e t t e r c o n t r o l .  With the changes a r i s e s a r e l a t e d change i n the emphasis of the r o l e of  the  M e d i c a l H e a l t h O f f i c e r i n m a i n t a i n i n g and promoting community h e a l t h . The cal  t r a d i t i o n a l r o l e s of the M e d i c a l H e a l t h O f f i c e r were l e g i s l a t e d , medi-  and management. The m e d i c a l r o l e of the M e d i c a l H e a l t h O f f i c e r i s i n d i v u d a l and  w i t h the community r o l e t a k i n g precedence.  community  The P u b l i c H e a l t h A c t and r e g u l a -  t i o n s p r e s c r i b e the M e d i c a l H e a l t h O f f i c e r s " o f f i c e r r o l e . "  ( T h i s i s the  in a l l provinces).  t h a t such powers  He  felt  be g i v e n to someone e l s e . a u t h o r i t y and  performing  t i o n of the h e a l t h u n i t .  t h e r e was  no evidence  to suggest  case  The management r o l e i s d e s c r i b e d as e x e r c i s i n g the the d u t i e s of the board w i t h r e s p e c t to the a d m i n i s t r a -  30  The r o l e s t o be expanded by f u t u r e M e d i c a l H e a l t h O f f i c e r s would be of  those  community h e a l t h c o n s u l t a n t , community h e a l t h s e r v i c e s c o - o r d i n a t o r , h e a l t h  r e s e a r c h e r and  planner.  With an i n c r e a s e d r o l e of the M e d i c a l H e a l t h O f f i c e r i n d i r e c t s e r v i c e s or a community h e a l t h r o l e , a reduced be expected. s t r a t o r and  Schnee proposed  a d m i n i s t r a t i v e r o l e i n the h e a l t h u n i t would  t h a t a l l a d m i n i s t r a t i o n be d e l e g a t e d to an  admini-  t h a t h e a l t h u n i t management committees be formed w i t h the M e d i c a l  H e a l t h O f f i c e r as m e d i c a l d i r e c t o r , the a d m i n i s t r a t o r as e x e c u t i v e d i r e c t o r  and  the n u r s i n g s u p e r v i s o r as n u r s i n g d i r e c t o r . A f u l l - t i m e M e d i c a l H e a l t h O f f i c e r should s e r v e a p o p u l a t i o n of 80,000 120,000.  F u l l - t i m e people should be shared r a t h e r than encouraging  Medical Health O f f i c e r s .  Rank o r d e r e d p r e f e r e n c e from most p r e f e r r e d c r e d e n -  t i a l s f o r a M e d i c a l H e a l t h O f f i c e r would 1.  3.  level  diploma  4. M.D.,  statistics,  be:  certification  2. masters  A l s o recommended was  part-time  without a d d i t i o n a l  training  a program of i n - s e r v i c e e d u c a t i o n , emphasizing  epidemiology,  economics, community o r g a n i z a t i o n and  planning,  community h e a l t h  and s o c i a l s e r v i c e c o - o r d i n a t i o n . The  comprehensive "job d e s c r i p t i o n " of the M e d i c a l H e a l t h O f f i c e r i n c l u d e s  the e i g h t primary r o l e s of D i r e c t o r ,  i n c l u d i n g i n p u t to a d m i n i s t r a t i o n , p u b l i c  r e l a t i o n s , and p e r s o n n e l management; O f f i c e r , w i t h enforcement and of  l e g i s l a t i o n ; E p i d e m i o l o g i s t / S t a t i s t i c i a n ; Educator;  s t a f f and  application  C o n s u l t a n t to h e a l t h u n i t  community; C o - o r d i n a t o r - h e a l t h u n i t s e r v i c e s ; C l i n i c i a n ;  Researcher/  31  Plann e r - f o r h e a l t h u n i t , community and department.  Goals  c o u l d be s t a t e d i n  each a r e a and measured by the c r i t e r i a o f f u l f i l l m e n t o f these g o a l s . Schnee l i s t s f o u r c a t e g o r i e s o f M e d i c a l H e a l t h I.  Officer:  D i r e c t o r - f u l l - t i m e M e d i c a l H e a l t h O f f i c e r a c t i n g as h e a l t h u n i t d i r e c t o r and community p h y s i c i a n .  II.  M e d i c a l D i r e c t o r - f u l l - t i m e M e d i c a l H e a l t h O f f i c e r a c t i n g as m e d i c a l d i r e c t o r o r h e a l t h u n i t and community p h y s i c i a n . s h i p r e s p o n s i b i l i t i e s go t o an e x e c u t i v e  I n t h i s case l e a d e r -  director.  I I I . C o n s u l t a n t - no management r o l e b u t o n l y o f f i c e r and c o n s u l t a n t r o l e s . The IV.  o t h e r f u n c t i o n s would be taken over by o t h e r p r o f e s s i o n a l s .  Part-time Medical Health  Officer.  C u r r e n t M e d i c a l H e a l t h O f f i c e r s i n Saskatchewan and A l b e r t a f u l f i l l , t o some e x t e n t , most o f the r e s p o n s i b i l i t i e s d e l i n e a t e d i n c a t e g o r y I which may be the most d e s i r a b l e .  Category  4 i s t h e most u n d e s i r a b l e .  c o n s i d e r a b l e leeway i n d e l i v e r i n g p u b l i c h e a l t h s e r v i c e s .  The c a t e g o r i e s l e a v e There i s no consensus  as to a common r o l e i n t h i s i n s t a n c e o r i n the case o f the o t h e r p r o v i n c e s . C o n s i d e r a b l e v a r i a t i o n e x i s t s a c r o s s the c o u n t r y . 6. L e g a l and A d m i n i s t r a t i v e P o s i t i o n o f the M e d i c a l H e a l t h  Officer  i n the B r i t i s h Columbia P u b l i c H e a l t h S e r v i c e B r i t i s h Columbia i s composed o f 18 h e a l t h u n i t d i s t r i c t s w i t h a M e d i c a l H e a l t h O f f i c e r i n a l l but two,(January 1979) who f u l f i l l s  an a d m i n i s t r a t i v e and  s e r v i c e f u n c t i o n , i n d e l i v e r y o f community h e a l t h s e r v i c e s . Mental h e a l t h and s o c i a l s e r v i c e s are administered  s e p a r a t e l y from community h e a l t h programs. There  are a l s o f o u r c i t y and one r e g i o n a l u n i t s which a r e autonomous but r e l y h e a v i l y on p r o v i n c i a l standards  and l e g i s l a t i o n f o r t h e i r program as w e l l . T h e i r M e d i c a l  32  H e a l t h O f f i c e r s meet every s i x months, w i t h p r o v i n c i a l M e d i c a l H e a l t h to  d i s c u s s mutual problems and programs of The  top o f f i c i a l  terial level.  Officers,  interest.  i n community programs i s a t the A s s i s t a n t Deputy M i n i s -  Both he and h i s a s s i s t a n t are s e l e c t e d from among the H e a l t h  Officer staff.  The  Deputy M i n i s t e r of H e a l t h i n B r i t i s h Columbia i s u s u a l l y a  physician. The H e a l t h U n i t areas a r e mapped (see page 3 3 ) and programs.  each u n i t has s e v e r a l  The M e d i c a l H e a l t h O f f i c e r i s r e s p o n s i b l e f o r a l l programs.  P u b l i c H e a l t h N u r s i n g i s headed by a N u r s i n g in various sub-offices.  These nurses  Supervisor with senior  are i n v o l v e d i n a wide v a r i e t y of programs  i n c l u d i n g the major ones of home c a r e and  l o n g term c a r e .  care program has more autonomy than the o t h e r s , h a v i n g  The new  i t s own  l o n g term  administrator i n  each h e a l t h u n i t , but t h i s p e r s o n a l s o comes under the M e d i c a l H e a l t h  Officer.  P u b l i c H e a l t h Nurses are a l s o i n v o l v e d i n s c h o o l h e a l t h programs, V.D. c o n t r o l , c h i l d and  adult h e a l t h conferences,  p o s t - n a t a l t r a i n i n g and  a l l immunizations,  and  birth  p r e - n a t a l and  c o u n s e l l i n g , h e a l t h e d u c a t i o n , and a g e n e r a l l y wide  v a r i e t y of h e a l t h u n i t f u n c t i o n s to the community. are a s s i s t e d  nurses  i n t h e i r d u t i e s by other r e g i s t e r e d  They are g e n e r a l i s t s and  nurses.  P u b l i c h e a l t h i n s p e c t i o n i s headed i n each h e a l t h u n i t by a a C h i e f P u b l i c H e a l t h I n s p e c t o r who  comes under the M e d i c a l H e a l t h O f f i c e r .  O f f i c e r i s appointed by government to be the c h i e f h e a l t h and for  A Medical  sanitary o f f i c i a l  the m u n i c i p a l i t y or union of m u n i c i p a l i t i e s to which he i s a p p o i n t e d  has a l l powers and a u t h o r i t y possessed  Health  and  he  by any H e a l t h O f f i c e r under the H e a l t h  (51)  ActV-^ In H e a l t h I n s p e c t i o n , the M e d i c a l H e a l t h O f f i c e r u s u a l l y d e l e g a t e s r e s p o n s i b i l i t y of l o o k i n g a f t e r the h e a l t h and  s a f e t y of the community environment  33  H e a l t h U n i t Boundaries G r e a t e r Vancouver Vancouver Richmond Burnaby North Shore Greater V i c t o r i a Regional D i s t r i c t East Kootenay Selkirk West Kootenay North Okanagan South Okanagan South C e n t r a l Upper F r a s e r Central Fraser Boundary Simon F r a s e r Coast G a r i b a l d i See B  V Kimberley Cranbrook jc^lliwack \ 13. 14. 15. 16. 17. 18.  )  C e n t r a l Vancouver I s l a n d Upper I s l a n d Cariboo Skeena Peace R i v e r Northern I n t e r i o r  •  '  ^  _  34  to H e a l t h  Inspectors.  Other departments i n h e a l t h u n i t s p r o v i d i n g p r e v e n t i v e h e a l t h s e r v i c e s to the community are d e n t a l h y g i e n e , n u t r i t i o n , engineering,  physiotherapy  i n each H e a l t h  U n i t who  S t a f f i n each H e a l t h  health education.  U n i t can v a r y  a m u n i c i p a l i t y may  by  law j o i n w i t h  o t h e r m u n i c i p a l i t i e s to e s t a -  The  A member of a R e g i o n a l  Health  District  no  l e g i s l a t i v e power.  O f f i c e r i s s e c r e t a r y on the Union Board and most H e a l t h  Health  to the A s s o c i a t e d  Boards of  O f f i c e r s i n B r i t i s h Columbia l e g a l l y need o n l y to be  q u a l i f i e d p r a c t i t i o n e r s but  c o u n c i l s u s u a l l y accept  i c e r s who  are r e s p o n s i b l e f o r d u t i e s under the M u n i c i p a l A c t as w e l l as  In the case where R e g i o n a l  well.  S e r v i c e s the M e d i c a l  p r o v i n c i a l appointment of M e d i c a l  Health  duly  Health  Off-  Health  D i s t r i c t s are r e s p o n s i b l e f o r a d m i n i s t r a t i o n  Health  O f f i c e r assumes d u t i e s under t h i s Act  In B r i t i s h Columbia, as elsewhere, M e d i c a l  H e a l t h O f f i c e r s are  c e r t a i n powers under the H e a l t h A c t f o r c o n t r o l and may  Units  a l l p r e s e n t l y have f u r t h e r t r a i n i n g i n p u b l i c h e a l t h .  Municipal  of H e a l t h  super-  Columbia.  Medical  Act.  council  c o n s u l t a t i v e f u n c t i o n s i n the a d m i n i s t r a t i o n of h e a l t h  have these boards which belong c o l l e c t i v e l y of B r i t i s h  by  Union Board e x e r c i s e s c o - o r d i n a t i n g ,  s e r v i c e s i n the a r e a w i t h i n i t s j u r i s d i c t i o n , but has The M e d i c a l  Supervisor  on which each m u n i c i p a l i t y i s r e p r e s e n t e d  a l s o be on the Union Board. and  There i s an o f f i c e  from 50-130 i n d i v i d u a l s .  s c h o o l t r u s t e e s and/or C o u n c i l members.  visory, advisory  environmental  i n each m u n i c i p a l i t y are the C o u n c i l o f the muni-  b l i s h a Union Board of H e a l t h  may  hearing,  manages the c l e r i c a l s t a f f f o r a l l these departments.  L o c a l Boards of H e a l t h c i p a l i t y but  and  speech and  as  given  abatement of n u i s a n c e s which  c o n s t i t u t e h e a l t h hazards, f o r c o n t r o l of communicable d i s e a s e s  and  for  35  i n s p e c t i o n of f a c i l i t i e s and  i n s t i t u t i o n s g i v i n g s e r v i c e to the p u b l i c and where  h e a l t h hazards  He has  can develop.  to see t h a t the p r o v i n c i a l to  legal authority (legislated  officer role)  r e g u l a t i o n s i n these areas a r e adhered to  pursuant  the H e a l t h Act of B r i t i s h Columbia. The  fined  l e g i s l a t e d O f f i c e r R o l e i s a l e g a l one  i n the H e a l t h A c t .  Public Health Inspector. t i o n and D i r e c t S e r v i c e s . form the substance  Much of t h i s r o l e  and i s one o f consensus, as  i s d e l e g a t e d to o t h e r s t a f f ,  de-  e.g.,  T h i s a r e a forms a r e l a t i v e l y s m a l l p a r t of A d m i n i s t r a I t i s not e x p l o r e d i n d e t a i l here and,  of a s e p a r a t e  study.  i n fact,  could  36  CHAPTER I I I METHOD  A survey q u e s t i o n n a i r e was m a i l e d  to a l l M e d i c a l H e a l t h O f f i c e r s i n B r i t i s h  Columbia, to e s t a b l i s h l e v e l s o f consensus on t h e i r r o l e d e s c r i p t i o n . twenty i n d i v i d u a l s i n v o l v e d i n t h i s survey, Health O f f i c e r s ,  There were  including f i f t e e n provincial  four c i t y Medical Health O f f i c e r s  (Vancouver, Richmond, North  and West Vancouver and Burnaby) and one r e g i o n a l M e d i c a l H e a l t h O f f i c e r and  Southern  Vancouver I s l a n d ) .  Medical  (Victoria  The l a t t e r f i v e M e d i c a l H e a l t h O f f i c e r s r u n  autonomous h e a l t h programs which r e l y c o n s i d e r a b l y on p r o v i n c i a l  standards.  There were s i x t y - f i v e q u e s t i o n s i n the survey, which was d i v i d e d i n t o seven s e c t i o n s .  These seven s e c t i o n s were designed  s e v e r a l areas concerned The  to e l i c i t  i n f o r m a t i o n on  with r o l e d e s c r i p t i o n of the Medical Health  Officer.  s e c t i o n s r e f e r r e d t o were: 1. P e r s o n a l E x p e r i e n c e and E d u c a t i o n a l Background 2. A t t i t u d e s towards the M e d i c a l H e a l t h O f f i c e r  Role  3. Workload and S e t t i n g 4. A d m i n i s t r a t i o n 5. D i r e c t  Services  6. R e l a t i o n s w i t h the M e d i c a l  Community  7. New D i r e c t i o n s E x p l a n a t i o n s o f the c o n t e n t s preceded  each s e c t i o n .  A l s o i n c l u d e d w i t h the q u e s t i o n n a i r e was a r e q u e s t f o r a one week budget" (see Appendix).  The M e d i c a l H e a l t h O f f i c e r s were asked  "time  t o keep a r e c o r d  of t h e i r a c t i v i t i e s d u r i n g any week and to c l a s s i f y them as t o D i r e c t  Services  o r A d m i n i s t r a t i o n and whether they were v e r y u s e f u l , u s e f u l o r m a r g i n a l l y  37  useful, in their The  opinion.  q u e s t i o n n a i r e employed the  anonymity c o u l d be m a i n t a i n e d .  The  'double b a l l o t ' method of r e t u r n whereby document c o u l d be p l a c e d w i t h i n a b l a n k  envelope w i t h i n an addressed envelope, on i t s r e t u r n . to  determine which h e a l t h u n i t s had  o p t i o n a l space was The  survey was  provided mailed  The 1978.  final  on A p r i l 28, 11,  1978  1978.  and  day  needed reminders.  An  a reminder was  g i v e n at  A t h i r d reminder, by way  c a l l t o each non-respondent, was  Following  l a t e d and  responded and  one  for signatures.  'Health O f f i c e r s C o u n c i l ' on May s o n a l telephone  not  T h i s would a l l o w  g i v e n on May  f o r r e c e i v i n g q u e s t i o n n a i r e s and  28,  1978.  time budgets was  t h i s r e s u l t s were examined, r e f e r e n c e d ,  of a p e r -  June  tabulated, cross  compared w i t h l i t e r a t u r e r e v i e w f i n d i n g s where a p p r o p r i a t e .  15, tabu-  Conclu-  s i o n s were drawn based upon the l e v e l of consensus among B r i t i s h Columbia Medical  H e a l t h O f f i c e r s about t h e i r r o l e d e s c r i p t i o n .  38  CHAPTER IV ANALYSIS OF DATA  In t h i s c h a p t e r , an e f f o r t w i l l be made to examine the l e v e l s o f consensus among B r i t i s h Columbia M e d i c a l H e a l t h O f f i c e r s  and to determine the extent to  which t h i s may be used t o d e f i n e a common r o l e . 1.  D e s c r i p t i o n of P o p u l a t i o n The  p o p u l a t i o n under study i n t h i s case a r e twenty M e d i c a l H e a l t h  i n the p r o v i n c e of B r i t i s h Columbia.  Officers  Seventeen responded to the q u e s t i o n n a i r e .  Four o f these work i n the l a r g e urban areas of V i c t o r i a , Vancouver, Burnaby and Richmond.  The remainder a r e d i s t r i b u t e d  throughout  the p r o v i n c e .  T a b l e s I , I I , and I I I d e s c r i b e the age d i s t r i b u t i o n , year o f g r a d u a t i o n f o r M.D.  or e q u i v a l e n t and l e v e l of q u a l i f i c a t i o n of B r i t i s h Columbia M e d i c a l  Officers.  TABLE I -  AGE DISTRIBUTION OF B.C. M.H.O.s 60+  50-59  40-49  30-39  3  5  5  3  TABLE I I - YEAR OF GRADUATION 1940-1949  1950-1959  1960-1969  5  5  6  TABLE I I I - LEVEL OF QUALIFICATION DPH 15  MSc 2  Attempting 4  FRCP  FRCP 4  Health  39  Twelve o f seventeen One q u a l i f i e d  r e c e i v e d t h e i r undergraduate  i n B r i t i s h Columbia.  r e c e i v e d a DPH from Toronto; British 2.  t r a i n i n g o u t s i d e Canada.  Four r e c e i v e d a DPH from t h e U.K. and e l e v e n  two pursued  the MSc r o u t e a t the U n i v e r s i t y o f  Columbia.  L e v e l s o f Consensus In the f o l l o w i n g d i s c u s s i o n we w i l l examine the l e v e l s o f consensus among  the M e d i c a l H e a l t h O f f i c e r s by c o n c e n t r a t i n g on: a. A l l o c a t i o n o f E f f o r t b. P r e p a r a t i o n f o r M e d i c a l H e a l t h O f f i c e r  roles  c. Role o f the M e d i c a l H e a l t h O f f i c e r i n , t h e t o t a l m e d i c a l  community  d. A t t i t u d e about Work and S e t t i n g e. New D i r e c t i o n s i n S e r v i c e s a. A l l o c a t i o n o f E f f o r t One measure o f consensus among M e d i c a l H e a l t h O f f i c e r s would be t h e s i m i l a r i t i e s between t h e a c t u a l time they spend i n a d m i n i s t r a t i o n and d i r e c t s e r vices.  Another measure would be the s i m i l a r i t i e s i n a t t i t u d e towards the k i n d s  of s e r v i c e s they should  deliver.  Perhaps the most c r i t i c a l  i s s u e s u r r o u n d i n g the q u e s t i o n o f whether a r o l e  e x i s t s has to do w i t h whether the M e d i c a l H e a l t h O f f i c e r i s p r i m a r i l y an adminis t r a t o r w i t h a p e r i p h e r a l r o l e i n d i r e c t s e r v i c e s or whether he i s p r i m a r i l y a community p h y s i c i a n ( p r o v i d e r o f s e r v i c e s ) w i t h o n l y a p e r i p h e r a l r o l e i n administration. T a b l e s IV, V and VI o f f e r i n s i g h t s as t o what M e d i c a l H e a l t h O f f i c e r s r e gard as e s s e n t i a l a d m i n i s t r a t i v e and d i r e c t  s e r v i c e f u n c t i o n s and how they  ocate t h e i r time t o a d m i n i s t r a t i o n and d i r e c t  services.  all-  40  TABLE IV -  M.H.O . S DIVISION OF LABOUR WITH RESPECT TO PERCENT OF TIME ALLOCATED TO ADMINISTRATION 1  % TIME 0 11 21 31 41 51 61 71 81 91  -  10 20 30 40 50 60 70 80 90 100  NUMBER OF M.H.O.'S  '  1 1 4 3 4  4  TABLE V - ESSENTIAL ADMINISTRATIVE FUNCTIONS AS LISTED BY RESPONDENTS E s s e n t i a l A d m i n i s t r a t i v e Functions Program P l a n n i n g & Implementation Meetings - S e n i o r S t a f f Conferences Reports f o r Union Board o f H e a l t h E v a l u a t i o n o f Program Outcomes Leadership D i s c u s s i o n o f S t a f f Problems O r i e n t a t i o n o f New S e n i o r S t a f f Delegation Duties M i n i s t e r i a l Problems - P u b l i c Complaints D e c i s i o n Making M e d i c a l Correspondence Between H e a l t h U n i t & Physician & Hospital S t u d y i n g Relevant I n f o r m a t i o n & New D i r e c t i o n s N e g o t i a t i n g Resources Administrative Circulars Budget  No. o f P o s i t i v e Respondents 8 4 3 3 3 3 2 2 2 2 2 2 1 1 1  41  TABLE VI - ESSENTIAL DIRECT SERVICES AS LISTED BY RESPONDENTS Essential Direct  Services  No.  Consultation to Hospitals & Physicians Consultation to M u n i c i p a l i t i e s , Regional D i s t r i c t s and Groups T h e r e i n V.D. and T.B. Comm. D i s e a s e C o n t r o l Problem S o l v i n g f o r S t a f f Advice to P u b l i c Family P l a n n i n g Nutrition Research Media Statements E n v i r o n m e n t a l Programs Comm. Care F a c i l i t i e s M e d i c a l C o n s u l t . - A i d t o Handicapped Home Care Epidemiology Maternal & C h i l d Health  Tables use  12 7 5 5 4 4 3 2 2 2 2 2 2 1 1 1  V I I , V I I I and IX e x p l o r e m a r g i n a l l y  o f e x t r a time ( i f a v a i l a b l e ) by M e d i c a l  which M e d i c a l  Health  O f f i c e r s regard  o f P o s i t i v e M.H.O.'s  useful administrative  Health  O f f i c e r s and those  functions, functions  as l a y a d m i n i s t r a t i v e ones.  TABLE V I I - MARGINALLY USEFUL ADMINISTRATIVE FUNCTIONS -- THOSE FUNCTIONS WHICH MEDICAL HEALTH OFFICERS WOULD PREFER TO DELEGATE TO SOMEONE ELSE Marginally Useful Administrative B u i l d i n g s & Space Personnel Matters O f f i c e Supervision Government Cars Equipment & S u p p l i e s S i g n i n g Cheques & Reports & Forms Answering Routine L e t t e r s Low Order P l a n n i n g Union B u s i n e s s Using Telpak Meetings With M i d d l e Management  Functions  No.  of P o s i t i v e Respondents 8 7 5 4 4 3 2 1 1 1 1  42  TABLE V I I I - HOW  MEDICAL HEALTH OFFICERS WOULD USE EXTRA TIME I F IT WERE AVAILABLE  Use of E x t r a Time  No. Of P o s i t i v e Respondents  Reading J o u r n a l s & E d u c a t i o n Upgrading Program P l a n n i n g Meeting With Other P h y s i c i a n s and Community Groups F i e l d Research A p p r a i s a l o f Community Needs & P r i o r i t i e s P i l o t & Special Projects Health Education C l i n i c a l Work Epidemiology W r i t i n g A r t i c l e s For P u b l i c a t i o n Staff Education Program E v a l u a t i o n G o l f & Contemplation  5 5 3 3 3 2 2 2 2 2 1 1 1  TABLE IX - LAY ADMINISTRATIVE FUNCTIONS - THOSE FUNCTIONS WHICH COULD BE DELEGATED TO A LAY ADMINISTRATOR Buildings Cars Personnel Matters S i g n i n g of Routine Documents Meetings Budget Office Administration  Communication Expanded O f f i c e S u p e r v i s i o n Co-ordination Health Education Media Releases Research P r o j e c t s E v a l u a t i o n Equipment & S u p p l i e s  The f o l l o w i n g p r i n c i p a l f i n d i n g s emerge from the p r e c e d i n g t a b l e s and the i n f o r m a t i o n on the a l l o c a t i o n of e f f o r t by the p r o v i n c e ' s M e d i c a l H e a l t h O f f i c e r s , i.  In terms of the gross a l l o c a t i o n o f time i t i s c l e a r t h a t no p r a c t i c a l consensus  i s e v i d e n t from the p e r c e n t time spent i n a d m i n i s t r a t i v e  as opposed to d i r e c t s e r v i c e s .  E l e v e n of the seventeen respondents  between f o r t y to seventy p e r c e n t o f time i n a d m i n i s t r a t i o n . a l l o c a t e s l e s s than twenty  areas spend  However, one  p e r c e n t o f time to a d m i n i s t r a t i o n , w h i l e f o u r  43  a l l o c a t e greater ii.  There i s l i t t l e  than n i n e t y percent  agreement w i t h r e g a r d s to a r e a s the M e d i c a l  O f f i c e r b e l i e v e s to be was  a l s o no  tive iii.  to m a r g i n a l l y  Health  functions. useful  There  administra-  functions.  role.  apparent areas of consensus i n the d i r e c t s e r v i c e s  Twelve out of f i f t e e n b e l i e v e d  h o s p i t a l s i s necessary.  the q u e s t i o n . )  There i s no  out  physicians  of seventeen d i d n ' t  understand  useful direct services.  consensus about what c o n s t i t u t e s l a y  f u n c t i o n s , but marginally  (Two  c o n s u l t a t i o n to  A l s o , twelve out of f i f t e e n b e l i e v e they weren't  performing marginally iv.  essential administrative  consensus w i t h r e s p e c t  There were two  and  of time i n t h i s manner.  those l i s t e d  administrative  correspond c l o s e l y w i t h the l i s t  useful administrative  to f i f t e e n  percent  of time on the average i s spent p e r f o r m i n g these f u n c t i o n s .  Twelve  out of seventeen f e l t and  any  functions.  lay administrator  s u b o r d i n a t e r o l e t o the M e d i c a l  Health  Ten  of  should  have a  supportive  O f f i c e r while eleven  they would l o s e e f f e c t i v e n e s s i f they t o t a l l y r e l i n q u i s h e d the ministrative role.  Thirteen f e l t  they c o u l d use  extra  felt ad-  administrative  help. b. P r e p a r a t i o n  for Medical  Health  O f f i c e r Role  Another measure of agreement would concern the method of p r e p a r i n g d i v i d u a l to be a M e d i c a l  Health  approach are c l o s e l y r e l a t e d .  Officer.  The  role itself  Consensus i n one  and  the  an i n -  educational  g e n e r a l l y would i n d i c a t e con-  sensus i n the o t h e r because of dependency between the two  variables.  44  Tables X, XI and X I I r a t e the v a r i o u s areas o f t r a i n i n g w i t h r e s p e c t adequacy, r e l e v a n c y and d e f i c i e n c i e s .  TABLE X - RATING OF AREAS OF TRAINING Area o f T r a i n i n g  Administration Epidemiology Env. E n g i n e e r i n g Microbiology Research & P l a n n i n g Preventive Medicine Public Health Int. Health H e a l t h Economics S o c i a l Medicine Occ. H e a l t h Mat. & C h i l d H e a l t h Lab. Procedures  Percentage  R a t i n g by Number of M.H.O. 's Excellent  Good  0 2 2 6 2 1 3 1 1 0 1 0 2  7 6 9 7 2 ' 12 7 3 1 6 4 9 '7  Fair  Poor  7 7 3 1 8 3 5 6 8 7 7 6 5  3 2 3 3 5 1 2 7 7 4 5 2 3  Total  21  80  73  47  =  243  9%  36%  33%  22%  =  100%  45  TABLE XI - RELEVANCY TO JOBS OF AREAS OF TRAINING Area o f T r a i n i n g  Relevancy Directly  Administration Epidemiology Env. E n g i n e e r i n g Microbiology Research & P l a n n i n g Preventive Medicine Public Health Int. Health H e a l t h Economics S o c i a l Medicine Occ. H e a l t h Mat. & C h i l d H e a l t h Lab Procedures  t o T h e i r Jobs By Number o f M.H.O.'s Relevant  16 15 13 14 11 15 17 4 1 10 7 13 6  Marginally Rel. 1 2 4 3 4 2  Not R e l .  2  11 13 7 9 4 11  1 3 1  TABLE X I I - DEFICIENT AREAS OF TRAINING D e f i c i e n t Area Of T r a i n i n g Epidemiology Administration P.R. & P o l i t i c s & H e a l t h Educ. S o c i a l Medicine Microbiology Occ. H e a l t h H e a l t h Economics Medicolegal Env. E n g i n e e r i n g Resident T r a i n i n g  Rated By Number o f M.H.O.'s  6 3 2 2 1 1 1 1 1  46  T a b l e s X I I I and XIV r e l a t e p r e v i o u s e x p e r i e n c e  i n o t h e r f i e l d s by M e d i c a l  H e a l t h O f f i c e r s and what they c o n s i d e r r e l e v a n t e x p e r i e n c e Health  f o r the M e d i c a l  Officer.  TABLE X I I I - PREVIOUS EXPERIENCE RECOMMENDED .FOR. COMMUNITY MEDICINE WITH AVERAGE NUMBER OF YEARS RECOMMENDED Fields  No. o f Respondents Recommending  General P r a c t i c e Pediatrics I n t e r n a l Medicine Psychiatry  Average No. o f Years o f E x p e r i e n c e Recommended  15 4 7 1  2.5 2.2 1.8 0.5  TABLE XIV - EXPERIENCE IN OTHER FIELDS BY CURRENT M.H.O.'s Field  No.  General P r a c t i c e I n t e r n a l Medicine Surgery Dermatology T r o p i c a l Medicine Occ. M e d i c i n e Emergency Anesthesia & P e d i a t r i c s  The  o f Respondents  Average No. Of Years E x p e r i e n c e 6.4 2.5 3.5 4 10 5 1 5  12 3 2 2 1 1 1 1  (part-time)  f o l l o w i n g p r i n c i p a l f i n d i n g s emerge from t h e t a b l e s and t h e i n f o r m a t i o n  on p r e p a r a t i o n f o r the M e d i c a l H e a l t h O f f i c e r  role.  i.  There i s no consensus on the r a t i n g o f areas o f t r a i n i n g .  ii.  There i s consensus about r e l e v a n c y to t h e j o b o f areas o f t r a i n i n g . P u b l i c h e a l t h , a d m i n i s t r a t i o n , epidemiology, m i c r o b i o l o g y , maternal  preventive  and c h i l d h e a l t h and environmental  medicine, engineering  47  are c o n s i d e r e d the most r e l e v a n t a r e a s .  H e a l t h Ecomonics  was  deemed the l e a s t r e l e v a n t a r e a . iii.  No agreement emerged on d e f i c i e n t areas of t r a i n i n g epidemiology  iv.  and  a d m i n i s t r a t i o n were those most commonly mentioned.  F i f t e e n out of seventeen  recommended M e d i c a l H e a l t h O f f i c e r s have  a background of g e n e r a l p r a c t i c e f o r 2 - 3 group had v.  although  years.  Twelve of  this  such a background.  Ten out of t h i r t e e n f e l t were undecided.  the F.R.C.P. should be o b t a i n e d ; f o u r  There was  no agreement on how  to o b t a i n the F.R.C.P.  c. Role of the M e d i c a l H e a l t h O f f i c e r i n the T o t a l M e d i c a l  Community  In t h i s s e c t i o n we w i l l be examining the degree of consensus amongst Medic a l H e a l t h O f f i c e r s i n r e l a t i o n s between themselves and at l a r g e .  We  the m e d i c a l  community  w i l l be l o o k i n g a t ways each b e l i e v e they can use the o t h e r more  e f f e c t i v e l y and where t h e r e a r e areas of i n t e r f e r e n c e . Tables XVI  and XVII query how  c l i n i c i a n s c o u l d use M e d i c a l H e a l t h  more e f f e c t i v e l y , where the h e a l t h u n i t might be i n t e r f e r i n g w i t h and how  Officers  clinicians  the M e d i c a l H e a l t h O f f i c e r might be used more e f f e c t i v e l y by  clinicians.  48  TABLE XV - AREAS OF CLINICAL PRACTICE THAT COULD BE DEALT WITH IN THE HEALTH UNIT Areas f o r H e a l t h U n i t  No.  of Positive  A l l Immunizations A l l V.D. Treatment & C o n t r o l Home Care Family Planning Nutrition W e l l Baby Care R e p o r t i n g o f Food P o i s o n i n g Communicable D i s e a s e s A l c o h o l Problems Long Term Care Speech Therapy & A u d i o l o g y Smoking C e s s a t i o n & L i f e s t y l e s  Respondents  7 4 3 3 2 2 1 2 1 1 1 1  TABLE XVI - WHAT M.H.O.'S THINK CLINICIANS REGARD AS AREAS OF INTERFERENCE BY THE HEALTH UNIT Areas o f I n t e r f e r e n c e M a t e r n a l & C h i l d Care A d v i c e Nutrition & Counselling R e l e a s e o f B i o l o g i c a l s & Lab. S e r v i c e s Communicable D i s e a s e Rheumatic Fever Program Home & Long Term Care Accidental Poisoning Patient Referral I m p l i c a t i o n s o f M e d i c a l Competence Vaccinations  No. of P o s i t i v e 8 2 2 2 1 1 1 1 1 1  Respondents  49  TABLE XVII - HOW M.H.O.'S THINK CLINICIANS COULD USE THE EFFECTIVELY Ways To Use The M.H.O. More E f f e c t i v e l y  M.H.O. MORE  No.' of P o s i t i v e Respondents  R e p o r t i n g & C o n s u l t a t i o n About Comm. D i s e a s e s Epidemiology Resource A d v i c e on T.B. & B.C. Integration of Health Services H e a l t h Care P l a n n i n g Bed U t i l i z a t i o n Committee H y p e r t e n s i o n Followup Nutrition Counselling O c c u p a t i o n a l H e a l t h Problems S o c i a l & Family Problems Vital Statistics Research By T r e a t i n g Him As An Equal Even Though He I s n ' t "Saving L i v e s "  8 2 2 2 1 1 1 1 1 1 I 1 1  Findings i.  The study i n d i c a t e d  some agreement  ( t h i r t e e n out o f seventeen) on  the q u e s t i o n t h a t t h e r e were areas i n c l i n i c a l p r a c t i c e t h a t should be d e a l t w i t h i n the h e a l t h u n i t , b u t Table XV i n d i c a t e s no consensus on the s p e c i f i c ii.  areas.  T h i r t e e n out o f seventeen  claimed  t h a t c l i n i c i a n s c o u l d use t h e  M e d i c a l H e a l t h O f f i c e r more e f f e c t i v e l y but T a b l e XVIII little iii.  illustrates  agreement as to how.  There was no agreement on whether c l i n i c i a n s r e g a r d the h e a l t h u n i t as i n t e r f e r i n g w i t h t h e i r p r a c t i c e and no consensus as t o s p e c i f i c areas o f c o n f l i c t .  iv.  There was no consensus as t o whether community medicine M e d i c a l H e a l t h O f f i c e r are too detatched  and t h e  from the mainstream o f  50  clinical v.  medicine  and  the h o s p i t a l ,  F i f t e e n out of seventeen  felt  t h a t the c l i n i c a l  people  regarded  M e d i c a l H e a l t h O f f i c e r s and h e a l t h u n i t s i n a f a v o u r a b l e manner. d. A t t i t u d e s About Work and S e t t i n g A l l s e v e n t e e n M e d i c a l H e a l t h O f f i c e r s claimed :  t h e i r j o b s , would not wish to change p o s i t i o n s and and p r o d u c t i v e .  Fifteen felt  f i n i n g t h e i r own  "role  There was  t h e r e was  they were s a t i s f i e d found  with  the work c h a l l e n g i n g  c o n s i d e r a b l e freedom and  autonomy i n de-  description."  no agreement on whether they spend most of t h e i r time doing what  they b e l i e v e d was  necessary  i n the community.  T h i r t e e n out of seventeen  felt  they would not welcome more d i r e c t i o n from H e a l t h O f f i c e r ' s C o u n c i l (twice annual meeting) i n d e f i n i n g t h e i r e. New  role.  Directions i n Service  In t h i s s e c t i o n consensus on judgements about f u t u r e r o l e s might g i v e some i d e a about where the M e d i c a l H e a l t h O f f i c e r i n B r i t i s h Columbia i s going. Only seven M e d i c a l H e a l t h O f f i c e r s f e l t should p l a y an i n c r e a s i n g r o l e . teen M e d i c a l H e a l t h O f f i c e r s f e l t Tables XVIII and XIX d i s e a s e s needing  t h e r e were s e r v i c e s i n which he  T h i s i s not consensus.  T h i r t e e n out of  t h e r e were c u r r e n t programs i n need of  sevenreview.  d e a l w i t h h e a l t h u n i t programs i n need of review  more a t t e n t i o n by M e d i c a l H e a l t h  Officers.  and  51  TABLE XVIII - HEALTH UNIT PROGRAMS IN NEED OF CRITICAL REVIEW Programs In Need Of C r i t i c a l  Review  M.H.O.'S  School.Health Immunization Maternal & C h i l d Health Prenatal Classes Health Education A l l Of Them Communicable D i s e a s e Lab. & E p i d . S e r v i c e s Telpak Rheumatic Fever Poison Control R e l a t i o n s With Mental H e a l t h Role o f Union Board o f H e a l t h P.H.N, ( n u r s i n g ) Environmental H e a l t h Research A d m i n i s t r a t i o n o f H e a l t h Department Office Administration  7 4 4 3 3 2 1 1 1 1 1 1 1 1 1 1 1 1  TABLE XIX - DISEASES MERITING MORE ATTENTION BY M.H.O.'S AND THOSE WITH FEASIBLE PROGRAMS TO ATTACK THEM D i s e a s e s M e r i t i n g More A t t e n t i o n From M.H.O.'s & H e a l t h U n i t s  M.H.O.'S  Endocrine, N u t r i t i o n a l & Metabolic Disorders 10 I n f e c t i o u s & P a r a s i t i c Diseases 9 Neoplasms 8 Congenital & P e r i n a t a l 7 Hypertension & Hematological Disorders 6 Pregnancy, C h i l d B i r t h , Puerperium 6 C i r c u l a t o r y , Resp. D i g e s t i v e and G - U 5 Neurological Disorders 2 Environmental D i s e a s e s 2 Industrial Accidents 2 Highway A c c i d e n t s 2 Geriatrics 1  F e a s i b l e Programs By No. o f M.H.O.'s  8 8 6 5 6 4 2 0 0 2 1 1  52  Findings The  l a s t t h r e e q u e s t i o n s o f t h e survey on which t h i s s e c t i o n i s based were  answered p o o r l y .  Three l e f t  them a l l out and s i x l e f t  out t h e l a s t  question.  i.  There i s no agreement on what programs a r e i n need o f review.  ii.  D i s e a s e s m e r i t i n g g r e a t e r a t t e n t i o n were s p e c i f i c a l l y l i s t e d but t h e r e wasn't agreement on them, even then, o r on f e a s i b l e programs to  iii.  a t t a c k the s p e c i f i c diseases.  Seven M e d i c a l H e a l t h O f f i c e r s o n l y l i s t e d  ten different services i n  which t h e M e d i c a l H e a l t h O f f i c e r s h o u l d p l a y an i n c r e a s i n g r o l e . There i s no consensus about where the M e d i c a l H e a l t h O f f i c e r i s going. 3.  L e v e l s o f Consensus Among Sub Groups T h i s d i s c u s s i o n w i l l be l i m i t e d t o a t t e m p t i n g  t o f i n d agreement amongst  "sub groups o f t h e p o p u l a t i o n o f study i n an attempt t o f i n d  consensus.  NEED FOR F.R.C.P. IN COMMUNITY MEDICINE TABLE XX - NEED FOR F.R.C.P. IN COMMUNITY MEDICINE AS DEPENDENT ON INDIVIDUAL LEVEL ACHIEVED Community M e d i c i n e  M.H.O.'s Having F.R.C.P.  Need f o r r e t a i n i n g F.R.C.P.  9  No need f o r r e t a i n i n g F.R.C.P.  1  Undecided  1  Working On F.R.C.P.  No F;R.C.P  1  2 2  1  Findings Nine out o f e l e v e n M e d i c a l H e a l t h O f f i c e r s h a v i n g  the F.R.C.P. f e l t i t  53  should be r e t a i n e d . felt  None o f t h r e e n o t having  i t should be r e t a i n e d as a requirement A l l who f e l t  the F.R.C.P. or working on i t  f o r the Medical Health  t h a t i t should be r e t a i n e d thought  t a i n c r e d i b i l i t y and s t a t u s w i t h o t h e r p h y s i c i a n s .  i t was n e c e s s a r y  to r e -  S e v e r a l mentioned the a d d i -  t i o n a l f i n a n c i a l rewards from the a d d i t i o n a l q u a l i f i c a t i o n . behaviour  Officers.  This i s r a t i o n a l  i n economic terms and c o n s i s t e n t w i t h the r e p o r t o f Anderson, D.O.  i n 1972. There was no consensus on the b e s t r o u t e t o o b t a i n i n g t h e F.R.C.P. S e l e c t i o n of Medical Health Candidates  Officers  are s e l e c t e d mainly  on t h e b a s i s o f assessment and i n t e r v i e w s  w i t h t h e a s s i s t a n t deputy m i n i s t e r and h i s a s s i s t a n t . as to whether t h i s approach was s a t i s f a c t o r y .  There was no consensus  However, t h r e e M e d i c a l  O f f i c e r s were n o t s a t i s f i e d w i t h t h i s approach.  Health  These t h r e e o n l y , a r e i n v o l v e d  i n t h e i r h e a l t h u n i t s w i t h r e s i d e n c y t r a i n i n g o f M e d i c a l H e a l t h O f f i c e r s and a r e on t h e f a c u l t y a t t h e U n i v e r s i t y o f B r i t i s h Columbia. ing  committee s h o u l d be i n v o l v e d , r e p r e s e n t e d  They f e l t  i n a d d i t i o n by f i e l d  H e a l t h O f f i c e r s and o t h e r f a c u l t y a t t h e U n i v e r s i t y o f B r i t i s h The  p r e v i o u s two c r o s s t a b u l a t i o n s i l l u s t r a t e d  discussed.  a screen-  Medical  Columbia.  some consensus i n t h e areas  S e v e r a l other attempts a t c r o s s t a b u l a t i o n , on t h e b a s i s o f age o f  M e d i c a l H e a l t h O f f i c e r s , e d u c a t i o n o f M e d i c a l H e a l t h O f f i c e r s , geographic  loca-  t i o n and s i z e o f h e a l t h u n i t , p l a c e o f t r a i n i n g and background e x p e r i e n c e were employed l o o k i n g f o r agreement i n v a r i o u s a r e a s .  No common p a t t e r n s were  eli-  c i t e d o t h e r than those mentioned. L i t t l e consensus was i l l u s t r a t e d Medical Health O f f i c e r  role.  i n t h i s data on d e f i n i t i o n o f a common  54  CHAPTER  V  SUMMARY AND RECOMMENDATIONS  In t h i s . s t u d y we have examined  the l i t e r a t u r e o f t h e c o u n t r i e s o f B r i t a i n ,  the U n i t e d S t a t e s and Canada l o o k i n g f o r consensus on t h e r o l e o f t h e M e d i c a l Health O f f i c e r .  The Canadian p r o v i n c e s have been looked a t and t h e B r i t i s h  Columbia M e d i c a l H e a l t h O f f i c e r examined erged on t h e r o l e o f t h e M e d i c a l H e a l t h  i n detail.  L i t t l e agreement has em-  Officer.  Since t h e r e i s n o t agreement, should a p o l i c y c l a r i f y i n g t h e r o l e he developed o r should the B r i t i s h Columbia M e d i c a l H e a l t h O f f i c e r c a r r y on as he has? He was found  t o be s a t i s f i e d w i t h t h e j o b , which he regards as c h a l l e n g i n g  and p r o d u c t i v e and, i n g e n e r a l , f e e l s he i s f u l f i l l i n g n i t y he s e r v e s .  t h e needs o f the commu-  C o n s i d e r a b l e freedom was d e s c r i b e d i n d e f i n i n g h i s own r o l e  and he p r e f e r r e d not to have t h i s tampered w i t h by d i r e c t i o n from t h e c o l l e c t i v e group o f M e d i c a l H e a l t h  Officers.  There i s n o t any d e s i r e i n the group t o develop role.  a p o l i c y c l a r i f y i n g the  Job s a t i s f a c t i o n and p e r s o n a l freedom, p o s s i b l y dependent on each o t h e r  here a r e e s s e n t i a l components  to e f f i c i e n t and e f f e c t i v e j o b f u n c t i o n i n g .  The  freedom i s i n h i b i t i n g development o f a common r o l e but one can h a r d l y argue i n favour o f such a r o l e i f t h e needs o f the community a r e b e i n g f u l f i l l e d d i v e r s i t y of roles. it  under a  The freedom i s a l s o i n d i v i d u a l i z i n g t h e r o l e and moulding  i n terms o f p e r c e i v e d c u l t u r a l and r e g i o n a l needs and demands. The l i k e l i h o o d of a c l e a r e r r o l e emerging i n t h e 1980's i s remote.  History  to date has r e v e a l e d a c o n s t a n t r e o r g a n i z a t i o n and r e - e v a l u a t i o n o f f u n c t i o n s . T h i s i s a c c e l e r a t e d by r a p i d c a l Health O f f i c e r  t e c h n i c a l , s o c i a l and p o l i t i c a l  changes.  The Medi-  i s i n v o l v e d w i t h too many areas of t h e s o c i a l m i l i e u t o be  55  forced into a clearer  paradigm.  I would say t h a t a c l e a r e r r o l e i n the f i e l d d e s i r a b l e a t t h i s time.  R e g i o n a l needs and  i s not r e a l l y n e c e s s a r y  personal preferences d i c t a t e  or the  j o b d e s c r i p t i o n w i t h i n the c o n t e x t of s e r v i c e s p r o v i d e d by the p r o v i n c e and  the  s e r v i c e s the M e d i c a l H e a l t h O f f i c e r might a d m i n i s t e r i n a d d i t i o n to these.  The  p e r s o n a l freedom does l e a v e more room f o r g o a l o r i e n t e d i n n o v a t i o n . I would d i s a g r e e w i t h Ian Macintosh who have "no  states Medical Health  r e c o g n i z a b l e o c c u p a t i o n a l g o a l and w i l l fade away as an  species."  In b e i n g a g e n e r a l i s t ,  tradition.  p e r s o n a l g o a l s i n tune w i t h r e g i o n a l  There are c o n f l i c t i n g g o a l s i n H e a l t h and  i s perhaps more c l e a r l y engendered i n Community H e a l t h and Medical Health O f f i c e r . f o r understanding experience.  obsolescent  each M e d i c a l H e a l t h O f f i c e r w i l l p i c k from the  " p o o l " the r e q u i r e d t o o l s to f i t h i s own needs, c u l t u r e and  The g e n e r a l knowledge n e c e s s a r y  this  the making of a  i n a l l h i s working  and p l a n n i n g s t r a t e g y should be the g o a l s of h i s t r a i n i n g  T h i s can mould an e f f i c i e n t and  e f f e c t i v e p l a n n e r who  these " c o n f l i c t i n g g o a l s " i n t o some k i n d of. o r g a n i z a t i o n a l sense. i s necessary  Officers  f o r t h i s , not another  stereotyped  can  areas and  direct  A generalist  specialist.  S e v e r a l areas where p o s s i b l e improvement c o u l d occur emerged. 1.  E l i m i n a t i o n of the m a r g i n a l l y u s e f u l a d m i n i s t r a t i v e f u n c t i o n s (10-15% o f  time) by expansion I t was  of the O f f i c e S u p e r v i s o r  role.  r e v e a l e d t h a t the B r i t i s h Columbia M e d i c a l H e a l t h O f f i c e r wants a  l a y a d m i n i s t r a t o r i n a s u p p o r t i v e r o l e to perform strative functions.  the m a r g i n a l l y u s e f u l admini-  He does not f e e l he would f u n c t i o n as e f f e c t i v e l y i f he  t o t a l l y r e l i n q u i s h e d h i s a d m i n i s t r a t i v e r o l e to someone e l s e . s i t i o n to Schwenger who  f e e l s that, two  T h i s i s i n oppo-  r o l e s should e v o l v e to f u l f i l l  either  56  an a d m i n i s t r a t i v e or a d i r e c t s e r v i c e r o l e . The  B r i t i s h Columbia M e d i c a l  Health, O f f i c e r i s b e i n g  t r a i n e d to perform  the m a j o r i t y of a d m i n i s t r a t i v e t a s k s he wishes to r e t a i n and t h i s to  I would recommend  continue.  A l a y a d m i n i s t r a t o r would have to be shared amongst t h r e e or more h e a l t h u n i t s to absorb the m a r g i n a l l y busy.  To m a i n t a i n  u s e f u l a d m i n i s t r a t i v e j o b s here and  l o c a l personal  contact  and  to remain  to be more c l o s e l y a l l i e d  tasks I would suggest expansion of the r o l e of the O f f i c e S u p e r v i s o r than c r e a t i o n of a new 2.  Re-evaluation  sophisticated lay administrator  of the p u b l i c h e a l t h e d u c a t i o n a l  improve d e f i c i e n t a r e a s such as epidemiology and to d i m i n i s h t r a i n i n g i n m a r g i n a l l y One i s one Lancet.  rather  job d e s c r i p t i o n .  program, p e r i o d i c a l l y ,  itself,  O f f i c e r the e p i d e m i o l o g i c a l  Parry, Morris  i s simply  training  too l i m i t e d  positions while  Officers felt  the  to g i v e the M e d i c a l  M o r r i s has  o f tomorrow's community p h y s i c i a n s w i l l depend on an  Health  tools.  t h a t epidemiology was  stated effective  F i f t e e n out o f seventeen  d i r e c t l y r e l e v a n t to  their  o n l y e i g h t r a t e d t h e i r t r a i n i n g as good or b e t t e r .  A d m i n i s t r a t i o n was O f f i c e r s and  and  t h a t the above w r i t e r s f e e l i s n e c e s s a r y .  i n t e l l i g e n c e system b u i l t up u s i n g e p i d e m i o l o g i c Health  program  i n t r o d u c t o r y course i n e p i d e m i o l o g y i n the p u b l i c  I would agree t h a t another more d e t a i l e d course i s needed. t h a t the success  and  r e l e v a n t areas such as h e a l t h economics.  of the most important, as s t r e s s e d by Heath and There i s p r e s e n t l y one  to  a d m i n i s t r a t i o n , at p r e s e n t  o f the weakest a r e a s i n the U n i v e r s i t y o f B r i t i s h Columbia MSc  h e a l t h o p t i o n which, by  Medical  to these  Health  felt  to be d i r e c t l y r e l e v a n t by  Economics m a r g i n a l l y  v e r s i t y of B r i t i s h Columbia course has  sixteen Medical  r e l e v a n t by the same number.  t h r e e u n i t s of economics and  Health The  h a l f of  Unithis  57  for  epidemiology.  A d m i n i s t r a t i v e t r a i n i n g i s a t l e a s t as l i m i t e d .  emphasis on epidemiology  and  a d m i n i s t r a t i o n and decreased  Increased  emphasis on h e a l t h  economics i s recommended. 3.  R e - e v a l u a t i o n of the s e l e c t i o n process f o r M e d i c a l H e a l t h O f f i c e r s to i n -  c l u d e the U n i v e r s i t y of B r i t i s h Columbia f a c u l t y and  f i e l d Medical Health Off-  i c e r s as w e l l as the h e a l t h department, i n s c r e e n i n g  candidates.  T h i s i s suggested  because of the o p i n i o n of the o n l y t h r e e M e d i c a l  O f f i c e r s d i r e c t l y i n v o l v e d i n r e s i d e n c y t r a i n i n g who 4.  Establishment  Health O f f i c e r s ,  the  concept.  of c l o s e r f o r m a l l i a i s o n w i t h " c l i n i c a l m e d i c i n e "  by  Medical  p r o b a b l y v i a the B r i t i s h Columbia M e d i c a l A s s o c i a t i o n to expand  the r o l e of "community p h y s i c i a n " and between the two  support  Health  further deteriorate traditional  barriers  p h y s i c i a n groups, which have i n h i b i t e d p r o g r e s s i n community  medicine. M e d i c a l H e a l t h O f f i c e r s f e e l they a r e regarded community, a t l a r g e .  There was  f a v o u r a b l y by the  a f e e l i n g t h a t the h e a l t h u n i t and  H e a l t h O f f i c e r c o u l d be used more e f f e c t i v e l y by the c l i n i c a l was  d i v i d e d o p i n i o n on how I t would be r e a s o n a b l e  to accomplish  people but  there  this.  clinical  t r a d i t i o n a l b a r r i e r s between the two  groups.  T h i s i s supported  i n e a t e areas of r e s p o n s i b i l i t y ,  the B.C.M.A.  by M o r r i s ,  At the p r e s e n t  t h e r e are o n l y l o c a l c o n t a c t s between M e d i c a l H e a l t h O f f i c e r s and some mutual p r o j e c t s through  be-  p h y s i c i a n s to enhance the breakdown  Schwenger and B r i t i s h Columbia M e d i c a l H e a l t h O f f i c e r s .  and  the M e d i c a l  to assume t h a t t h e r e should be c l o s e r l i a i s o n  tween M e d i c a l H e a l t h O f f i c e r s and of  medical  time,  practitioners  Mutual f o r m a l d i s c u s s i o n s to d e l -  to determine the mechanism f o r u s i n g each o t h e r  58  more e f f e c t i v e l y and  to improve o r g a n i z a t i o n of areas t h a t can be d e a l t w i t h  more e f f i c i e n t l y and  e f f e c t i v e l y i n the h e a l t h u n i t and  necessary.  Public Health  Can  t h i s be done s o l e l y i n the h e a l t h u n i t  Nurses w i t h a p p r o p r i a t e  r e f e r r a l to  S u r e l y t h i s a t t i t u d e of " f a v o u r a b l e ence" of c l i n i c i a n s towards M e d i c a l and  Health  The  "government p h y s i c i a n s  of the p r i v a t e p r a c t i t i o n e r " have l i m i t e d the M e d i c a l  everything  Health  greatest  the other  be-  time. es-  elucidated  i n the f i f t y years  Medical  Health  the h e a l t h u n i t .  One  following  to l o s e income  might expect  O f f i c e r i n t e r f e r e n c e would be g r e a t e s t  a r e a s where the supply  of p h y s i c i a n s  extreme where demand exceeds supply  that  in  exeeds demand f o r s e r v i c e s .  of s e r v i c e s , r e l i e f of some  s e r v i c e s by h e a l t h u n i t s might be welcomed by p r i v a t e p h y s i c i a n s . t i o n of t h i s problem i s n ' t l i k e l y u n t i l a l l p h y s i c i a n s could  I  century.  some of h i s f u n c t i o n s are assumed by  h e a v i l y doctored At  f e l t was  f e e f o r s e r v i c e p r i v a t e p r a c t i t i o n e r however does stand  o p p o s i t i o n to any  realm  to g a i n i n expanding h i s r o l e of "community p h y s i c i a n " ,  the n a t u r e of t h i s s p l i t which he  if  i n the  to a t t a c k them at t h i s more f a v o u r a b l e  M a c i n t o s h , i n the U.K.,  The  traditional  O f f i c e r and  p e c i a l l y i f these b a r r i e r s are l e s s e n i n g .  the t u r n of the  interfer-  O f f i c e r s i s conducive to mutual d i s -  c l a r i f i c a t i o n of i n d i v i d u a l a r e a s of p r a c t i c e .  l i e v e the i n c e n t i v e l i e s w i t h him  by  clinicians?  regard with only o c c a s i o n a l  b a r r i e r s r e v o l v i n g around i n t e r f e r e n c e s by  He has  are  For example, the c o s t s o f such t h i n g s as " w e l l baby c a r e " i n c l i n i -  c a l p r a c t i c e are a s t r o n o m i c a l .  cussions  c l i n i c a l practice  Total resolu-  are s a l a r i e d .  This  topic  form the substance of f u r t h e r study. Requirements t h a t new  Medical  c a t i o n s to m a i n t a i n c r e d i b i l i t y and  Health  O f f i c e r s o b t a i n the F.R.C.P. q u a l i f i -  e q u a l i t y w i t h t h e i r c l i n i c a l p e e r s , thus  59  facilitating  mutual p u r s u i t s .  Nine o f e l e v e n credibility facilitate  h a v i n g the F.R.C.P. f e l t i t should  and s t a t u s w i t h o t h e r dialogue  physicians.  physicians.  be r e t a i n e d t o r e t a i n  I b e l i e v e i t would  obviously  between the groups, p a r t i c u l a r l y w i t h s p e c i a l i s t  clinical  I t i s a u n i v e r s a l l y a c c e p t e d q u a l i f i c a t i o n i n t h i s c o u n t r y amongst  physicians. In c o n c l u s i o n  the M e d i c a l  person i n the planning and  Health  O f f i c e r i n B r i t i s h Columbia can be a key  and d e l i v e r y o f H e a l t h  p u b l i c o p i n i o n have played  a part  T h i s i s the crux of the M e d i c a l  "enforcer"  of the Health  Health  clinical He w i l l  see the " f o r e s t " , i n most cases,  He w i l l remain the  and e n v i r o n m e n t a l t o x i n s .  always t o be h i s g r e a t e s t  i n the " t r e e s " as have so many o f  colleagues. c o n t i n u e to do h i s own t h i n g , r e - e v a l u a t i n g  r o l e from time t o time. it  i n an o r g a n i z a t i o n a l  A c t and he w i l l keep h i s " c l i n i c a l eye" sharpened w i t h  a s s e t and h o p e f u l l y he w i l l never l o s e h i m s e l f his  Officer.  knowledge o f such t h i n g s as communicable d i s e a s e s He can s t i l l  priorities  Someone i s always needed who can l o o k  the whole complex o f h e a l t h s e r v i c e s and p u l l i t t o g e t h e r  sense.  his  Department  i n the course o f t h i s r o l e but he has had  much freedom t o d e f i n e h i s own d i r e c t i o n . at  Services.  and r e o r g a n i z i n g h i s  He has n o t , t o date^reached consensus on t h i s r o l e and  i s u n l i k e l y t h a t he ever w i l l .  this w i l l a l t e r h i s valuable  I t i s a l s o u n l i k e l y , i n my o p i n i o n ,  ongoing c o n t r i b u t i o n s to H e a l t h  Systems.  that  60  References  1.  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D i s c u s s i o n Services  Paper P l a c e s  on P u b l i c H e a l t h P r o f e s s i o n a l s  1978. *  R e p o n s i b i l i t y for Health  and P h y s i c i a n s .  CM.A.J.,  A p r i l 8, 78, 118, 829-30. 51.  H e a l t h A c t o f B r i t i s h Columbia, Chapter 170,  52.  M c i n t o s h , Ian D., On Having Been a M e d i c a l O f f i c e r o f H e a l t h . H l t h . 69(5) .375-77  53.  1960. Can. J . Pub.  Sept/Oct 78.  M c i n t o s h , I a n D., The Canadian M e d i c a l O f f i c e r o f H e a l t h : F u t u r e . Can. J . Pub. H l t h .  P e r s o n a l Communications  69(5) 355-59 Sept/Oct 78.  A Look a t H i s  64  References  Read But Not C i t e d  Mackenzie, R. A l e c , The Time Trap, McGraw-Hill Morgan R.W. 1977.  Paperbacks 1972.  P r o s p e c t s f o r P r e v e n t i v e M e d i c i n e , Ont. Economic C o u n c i l  Abramson, J.H., Survey Methods i n Community M e d i c i n e , C h u r c h i l l - L i v i n g s t o n e 1974. B i l l e t , R.O., Adams & Co.  P r e p a r i n g T h e s i s and o t h e r Typed M a n u s c r i p t s ,  Littlefield  B a t t i s t e l l a , R.M., C h e s t e r , T.E., Role o f Management i n H e a l t h S e r v i c e s i n B r i t a i n and the U n i t e d S t a t e s , L a n c e t , Mar. 18/72. M e d i c a l O f f i c e r o f H e a l t h , From a s p e c i a l correspondent, 4, 166-167.  B.M.J., 1972,  The P a r t - t i m e M e d i c a l O f f i c e r o f H e a l t h , A l a n Tomlinson, H l t h . Mar/Apr 71, 164.  Can. J . Pub.  N i s b e t , E.R., M e d i c a l O f f i c e r of H e a l t h , H l t h . B u l l e t i n ,  33, 164, J a n . 75.  Robertson, J.S., The D i s t r i c t 124-5, May 1975.  Community  P h y s i c i a n , Pub. H l t h . , 8 9 ( 4 ) ,  BIBLIOGRAPHY  APPENDIX  65,  MEDICAL HEALTH OFFICER QUESTIONNAIRE  Please note:  The e n c l o s e d q u e s t i o n n a i r e has been designed t o s o l i c i t from you, i n an attempt t o c l a r i f y  the current s i t u a t i o n .  gone i n t o i t to minimize the time needed t o answer i t .  information  Much work has  The "double b a l l o t "  method o f r e t u r n can be used t o m a i n t a i n anonymity by p l a c i n g the q u e s t i o n n a i r e w i t h i n a b l a n k envelope and p l a c i n g t h i s w i t h i n an addressed envelope. I w i l l r e c e i v e the b l a n k envelope from the s e c r e t a r y who can check who has responded. An o p t i o n a l space i s p r o v i d e d a t t h e end o f t h e q u e s t i o n n a i r e i f you wish to g i v e your name.  66  TO:  A l l M e d i c a l H e a l t h O f f i c e r s i n B.C.  RE:  The "Role o f the M e d i c a l H e a l t h O f f i c e r  (M.H.O.) i n B.C."  As you know, d e s p i t e the growing concern w i t h the r o l e o f the M.H.O. i n Canada, t h e r e i s l i t t l e In i n B.C."  light  of this,  i n f o r m a t i o n on the  I have d e c i d e d t o do a t h e s i s on "The  as a p a r t o f the requirements  I am hoping  topic.  f o r the MSc.  Role o f the M.H.O.  (health services planning).  t h i s i n f o r m a t i o n may be o f some f u t u r e use i n terms o f s e l e c -  t i o n , e d u c a t i o n , o r g i n i z a t i o n o f f u n c t i o n s , d e l i n e a t i o n o f "job d e s c r i p t i o n " and d e f i n i t i o n o f the M.H.O. As you w i l l d i s c o v e r i n the q u e s t i o n n a i r e I am l o o k i n g a t i n d i v i d u a l backgrounds and examining  the job d e s c r i p t i o n i n terms o f a t t i t u d e s  concerning  d i r e c t s e r v i c e s and a d m i n i s t r a t i o n . A l s o I w i l l be r e v i e w i n g the l i t e r a t u r e i n o r d e r t o examine what the r o l e of  the M.H.O. elsewhere,  and w i l l attempt  t o c o r r e l a t e t h i s w i t h the d a t a  As u s u a l w i t h t h e s e p r o j e c t s , the time element i s important. ing  I am attempt-  t o do most o f t h i s work p r i o r t o assuming my d u t i e s as M.H.O. i n the  on J u l y 1 s t , 1978.  An answer w i t h i n the next  Cariboo  two t o t h r e e weeks would be most  h e l p f u l i n a l l o w i n g me t o get t h i s t o g e t h e r w i t h i n the time  frame.  Thank you f o r your c o n s i d e r a t i o n and f o r any h e l p you can g i v e .  Yours s i n c e r e l y ,  here.  QUESTIONNAIRE  A.  Personal  Experience  arid E d u c a t i o n a l  Background  An i n d i v i d u a l ' s background, t r a i n i n g and e x p e r i e n c e b e a r i n g on how he approaches h i s work.  Therefore,  u s u a l l y have a s t r o n g  i n t h i s s e c t i o n , we would  l i k e t o o b t a i n some i n f o r m a t i o n on these f a c t o r s . 1.  Your age  2.  Where d i d you r e c e i v e your M.D. ( ) British  ( ) 30-39  ( ) 40-49  ( ) 50-59  ( ) 60+  or equivalent?  Columbia.  ( ) Canada, o t h e r than B.C.  Specify  ( ) Outside  Specify  Canada.  3.  In what year d i d you graduate?  ( )  ( )  ( )  ( )  4.  Where d i d you r e c e i v e your t r a i n i n g i n Community M e d i c i n e ?  (Public Health  and P r e v e n t i v e M e d i c i n e ) ( ) British  Columbia•  ( ) Canada, other ( ) Outside 5.  than B.C.  Canada.  Specify Specify  What i s your l e v e l o f q u a l i f i c a t i o n i n Community M e d i c i n e ? ( ) D.P.H., o r e q u i v a l e n t ( ) M.P.H., M S c ,  or equivalent,  ( ) F.R.C.P. ( ) Other. 6.  Are you s t i l l working on f u r t h e r q u a l i f i c a t i o n s i n t h i s ^ (  7.  Specify  ) Yes  ( ) No  I f yes, please s p e c i f y  field?  68  8.  How many y e a r s o f e x p e r i e n c e d i d you have i n Community M e d i c i n e  prior  to becoming an M.H.O. i n B.C.? ( 9.  (  )  Years  How many y e a r s o f e x p e r i e n c e have you had as an M.H.O. i n B.C.? (  10.  )  )  (  ) Years  .... as an M.H.O. o u t s i d e B.C. (  )  (  )  Years  How many y e a r s o f e x p e r i e n c e have you had i n o t h e r f i e l d s o f medicine? (  )  (  )  Years  S p e c i f y f i e l d s and y e a r s 11.  Could you i n d i c a t e r o u g h l y how many y e a r s , i n t o t a l , you expect t o p r a c t i c e as an M.H.O.? (  B.  )  )  Years  (  ) No  A t t i t u d e Towards The M e d i c a l H e a l t h O f f j e e r In t h i s  role,  (  Role  s e c t i o n we would l i k e t o o b t a i n your views about your  present  and t o i n d i c a t e how you f e e l about the c u r r e n t approaches f o r r e c r u i t i n g  M.H.O. c a n d i d a t e s and f o r t r a i n i n g them.  T h i s w i l l g i v e some i n d i c a t i o n about  the p r e s e n t f u n c t i o n o f the M.H.O. 12.  P i c k the statement  which b e s t d e s c r i b e s the way you f e e l towards your  p r e s e n t f i e l d as an M.H.O. a.  ( ) I am s a t i s f i e d  b.  ( ) I am n o t r e a l l y  c.  ( ) I am n o t s a t i s f i e d and have attempted  I f you s e l e c t e d  and would n o t want t o change f i e l d s . s a t i s f i e d b u t have n o t attempted  t o change f i e l d s .  12a., p l e a s e go on t o q u e s t i o n 16.  I f you s e l e c t e d b . o r c , p l e a s e c o n t i n u e  t o change f i e l d s .  69  13.  Why  are you not  14.  I f you were s t a r t i n g over a g a i n to choose a c a r e e r , which of the f o l l o w i n g statements  satisfied?  comes c l o s e s t to i n d i c a t i n g your c h o i c e ?  ( ) I would choose community medicine  but  i n another  area besides  being  an M.H.O. ( ) I would not choose community  medicine.  ( ) I don't know. 15.  I f you d i d not choose community medicine,  can you i n d i c a t e what you might  have chosen?  16.  G e n e r a l l y speaking, how  would you r a t e the adequacy o f your t r a i n i n g  and  e d u c a t i o n a l program f o r the p o s i t i o n of M.H.O.? ( ) 17.  Excellent  ( )  Good  ( )  Fair  ( )  Poor  ( )  Undecided  With r e s p e c t to each p a r t i c u l a r a r e a of t r a i n i n g t h a t you r e c e i v e d would you  rate? Excellent  Administration Epidemiology Environmental E n g i n e e r i n g Microbiology Research & P l a n n i n g Preventive Medicine Public Health I n t e r n a t i o n a l Health H e a l t h Economics S o c i a l Medicine Occupational Health Maternal & C h i l d Health L a b o r a t o r y Procedures Other ( S p e c i f y )  Good  Fair  Poor  Undecided  how  70.  18.  P l e a s e r a t e your areas of t r a i n i n g i n terms of t h e i r r e l e v a n c e to your present  position. Directly Relevant  Marginally Relevant  Not Relevant  Administration Epidemiology Microbiology Environmental E n g i n e e r i n g Research & P l a n n i n g Preventive Medicine Public Health International Health H e a l t h Economics S o c i a l Medicine Occupational Health Maternal & C h i l d Health L a b o r a t o r y Procedures Other ( S p e c i f y ) 19.  In your o p i n i o n , d i d your t r a i n i n g program not i n c l u d e some areas needed and what were  20.  you  they?  In the l i g h t of your t r a i n i n g and work e x p e r i e n c e , f o r s e l e c t i n g p r o s p e c t i v e M.H.O.'s, p r o d u c i n g  i s the p r e s e n t  c a n d i d a t e s who,  you  approach feel,  have the k i n d s of backgrounds and p e r s o n a l q u a l i f i c a t i o n s f o r f u l f i l l i n g this  role?  ( ) Yes 21.  Are you ( ) Yes  ( ) No  ( ) Undecided  s a t i s f i e d w i t h the c u r r e n t methods of r e c r u i t i n g ( ) No  candidates?  ( ) Undecided  I f your answer i s "Yes" or "Undecided" p l e a s e go to q u e s t i o n I f your answer i s "No",  please  continue.  #24.  71  22.  Why a r e you n o t s a t i s f i e d ?  23.  How would you ammend the p r e s e n t method? ( ) Don't know. ( ) Specify  24.  Do you f e e l t h a t a p p l i c a n t s  should be t r a i n e d o r e x p e r i e n c e d i n other  f i e l d s o f medicine? ^ ( 25.  ) Yes  ( ) No  ( ) Undecided  I f you answered "Yes", c o u l d you i n d i c a t e what you t h i n k a r e t h e r e l e v a n t f i e l d s and recommended minimum number o f y e a r s e x p e r i e n c e r e q u i r e d one  26.  i n any  o f them?  R e c o g n i z i n g t h e F.R.C.P. as t h e f u l l  s p e c i a l t y q u a l i f i c a t i o n i n community  m e d i c i n e , which approach would you recommend ( ) D.P.H. & a s s i s t a n t d i r e c t o r  (Trainee).  ( ) M.P.H. o r MSc. & a s s i s t a n t d i r e c t o r ( ) Other  f o r achieving i t ?  (Trainee).  (specify)  ( ) Undecided 27.  In your view, i s t h e r e a need f o r a c l i n i c a l all,  i n this  ) Yes  field?  ( ) No  ( ) Undecided  s p e c i a l t y , o r F.R.C.P., a t  22:  28.  I f "Yes", c o u l d you i n d i c a t e why?  C.  Workload  & Setting  We would  l i k e to f i n d out about a t y p i c a l week and what you f e e l about i t s  r e l e v a n c e to the community. job 29.  T h i s s e c t i o n w i l l r e v e a l some i d e a s about your  effectiveness. G i v e n t h a t the s e t workload i s 37 hours, how  many hours do you work i n a  t y p i c a l week. ( ) 30.  ( ) Hours  G e n e r a l l y s p e a k i n g , do you f i n d ( ) Yes  31.  ( ) No  ( ) Undecided  What k i n d o f freedom do you have i n d e f i n i n g your own ( ) Considerable  32.  the work c h a l l e n g i n g and p r o d u c t i v e ?  ( ) Limited  "job d e s c r i p t i o n ? "  ( ) None  Would you welcome more d i r e c t i o n , i n d e f i n i n g your r o l e , from H e a l t h O f f i c e r s ' Council? ) Yes  ( ) No  ( ) Undecided  33.  I f "Yes", i n what areas would you f i n d d i r e c t i o n most u s e f u l ?  34.  P i c k the f o l l o w i n g statement which i s most c h a r a c t e r i s t i c of how your time i s spent f u l f i l l i n g  you  the needs o f the community i n community  medicine? ( ) Most o f my  time i s spent d o i n g what I b e l i e v e needs to be done i n  the community.  feel  73  ( ) Fifty  to seventy p e r c e n t o f my  time i s spent doing what I b e l i e v e  needs to be done i n the community. ( ) Some o f my  time i s spent d o i n g what I b e l i e v e needs to be done i n  the community. ( ) Seldom i s any o f my  time spent doing what I b e l i e v e needs to be  done i n the community. D.  Administration Here we w i l l e x p l o r e a d m i n i s t r a t i v e t a s k s and t h e i r importance to you i n  f u l f i l l i n g your r o l e i n the community. 35.  What approximate percentage o f time do you spend i n Administration  ( )  ( ) %  Direct  ( )  ( ) %  Services  100  %  36.  In your view, what a r e the e s s e n t i a l a d m i n i s t r a t i v e f u n c t i o n s f o r you?  37.  Are you c u r r e n t l y p e r f o r m i n g any a d m i n i s t r a t i v e f u n c t i o n s which you  feel  are m a r g i n a l l y important? ) Yes 38.  ( ) No  ( ) Undecided  I f "Yes", what are these f u n c t i o n s and what percentage o f t o t a l time do you spend d o i n g them? ( a p p r o x i m a t e l y ) realistic  (Please ensure your e s t i m a t e i s  i n terms of your e s t i m a t e i n q u e s t i o n #5).  74  38.  (continued) M a r g i n a l l y Relevant  A d m i n i s t r a t i v e Tasks  Percentage of Time  39.  I f you had  e x t r a time what would you do w i t h i t ?  40.  P i c k the statement which b e s t r e p r e s e n t s your view about the time  you  spend i n a d m i n i s t r a t i o n . ( ) I am  t o t a l l y s a t i s f i e d w i t h the amount of time spent  ( ) I am  reasonably  ( ) I am  somewhat  ( ) I am v e r y 41.  satisfied. dissatisfied.  dissatisfied.  A l t h o u g h M.H.O.s are now  t o t a l l y responsible for administering their  some i n the f i e l d b e l i e v e t h a t t h e r e may "lay  administrator"; others Do you ( ) Yes I f you  i n administration.  ( ) No answered "No"  be a p l a c e i n the h e a l t h u n i t f o r a  disagree.  f e e l t h e r e i s room f o r one  i n your u n i t ?  ( ) Undecided or "Undecided", proceed to q u e s t i o n  I f you answered "Yes", p l e a s e  unit,  continue...  #44.  75  42.  What a d m i n i s t r a t i v e o r o t h e r  f u n c t i o n s do you f e e l they c o u l d assume?  43.  P i c k the statement which best r e p r e s e n t s  your o p i n i o n about the r o l e o f  a "lay administrator" i n r e l a t i o n to yourself. ( ) Supportive  & Subordinate r o l e .  ( ) Division of labour/Division of control. ( ) Superior 44.  and d i r e c t i n g r o l e .  Can the M.H.O. f u n c t i o n e q u a l l y e f f e c t i v e l y i f he r e l i n q u i s h e s h i s p o s i t i o n as a d m i n i s t r a t o r ( ) Yes  E.  Direct The  o f the h e a l t h u n i t ?  ( ) No  Services  approaches which the M.H.O. takes i n meeting the needs o f t h e i r  p a r t i c u l a r communities w i l l v a r y depending on the l o c a t i o n and s i z e o f the area.  We w i l l  examine these s e r v i c e s and how you  f e e l about t h e i r worth i n  terms o f your p o s i t i o n . 45.  In your o p i n i o n , what are the e s s e n t i a l " d i r e c t s e r v i c e s " f u n c t i o n s you fulfill?  46.  Are you c u r r e n t l y p e r f o r m i n g any " d i r e c t s e r v i c e " f u n c t i o n s which you f e e l are m a r g i n a l l y ^ (  ) Yes  important?  ( ) No  ( ) Undecided  47.  I f "Yes", what a r e these f u n c t i o n s and what p e r c e n t o f t o t a l  time  (approximately) do you spend doing them?  48.  Do you f e e l t h a t i t i s worth the time and e f f o r t gain further e x p e r t i s e i n p a r t i c u l a r areas,  f o r the M.H.O.s t o  (eg. epidemiology)  so they  might a c t as r e s o u r c e people f o r each o t h e r and o t h e r s i n the p r o v i n c e ? ( ) Yes F.  ( ) No  ( ) Undecided  R e l a t i o n s With The M e d i c a l Community One a r e a which i s o b v i o u s l y c u r c i a l f o r the M.H.O. i s the q u a l i t y o f  t h e i r r e l a t i o n s h i p w i t h t h e i r c o l l e a g u e s i n t h e m e d i c a l community.  In t h i s  s e c t i o n we w i l l pursue your g e n e r a l views about how the M.H.O. should  relate  to the m e d i c a l community, and v i s e - v e r s a . 49.  Do you f e e l t h a t community medicine and the M.H.O. a r e too detached  from  the mainstream o f c l i n i c a l medicine and the h o s p i t a l ? ( ) Yes 50.  ( ) No  ( ) Undecided  In your view, a r e t h e r e areas p r e s e n t l y d e a l t w i t h i n c l i n i c a l which should be d e a l t w i t h i n the h e a l t h u n i t ? ^,(  51.  ) Yes  ( ) No  ( ) Undecided  I f "Yes", what a r e these areas?  practice  n  52,  Do you t h i n k the " C l i n i c i a n s " r e g a r d the h e a l t h u n i t as i n t e r f e r i n g w i t h some areas o f t h e i r ( ) Frequently  practice? ( ) Occasionally  ( ) Seldom  ( ) Never  53.  What a r e these areas o f i n t e r f e r e n c e , i f any?  54.  How do you f e e l the " C l i n i c i a n s " r e g a r d your f u n c t i o n w i t h r e s p e c t t o them and the community a t l a r g e ? ( ) Very F a v o u r a b l y  55.  Could " C l i n i c i a n s " , ^ (  ) Yes  ( ) No  ( ) Favourably  ( ) Not F a v o u r a b l y  i n your view, use the M.H.O. more e f f e c t i v e l y ? ( ) Undecided  56.  I f "Yes", c o u l d you i n d i c a t e i n what p o s s i b l e ways?  G.  New D i r e c t i o n s In t h i s , the f i n a l  s e c t i o n , we would l i k e t o determine  changes i n the r o l e o f the M.H.O.s i n community m e d i c i n e .  your views  about  We would l i k e  your  o p i n i o n s on the need o f r e v i e w i n g some o f the c u r r e n t d i r e c t s e r v i c e programs, and we would l i k e t o know i f any a r e a s o f d i r e c t s e r v i c e s need 57.  Do you c o n s i d e r the M.H.O. a h e a l t h p l a n n e r and r e s e a r c h e r ? ) Yes  58.  expanding.  ( ) No  ( ) Undecided  I f "Yes", i s he b e i n g t r a i n e d e f f e c t i v e l y f o r t h i s ( ) Yes  ( ) No  ( ) Undecided  role?  78  59.  Are  t h e r e any  direct  s e r v i c e s i n which you  f e e l the M.H.O. should  play  a greater role? ( ) Yes  ( ) No  ( ) Undecided  60.  I f "Yes", what are these s e r v i c e s and  61.  In your o p i n i o n , a r e t h e r e any critical l ( ) Yes  how  can he p l a y a r o l e ?  c u r r e n t programs which a r e i n need of  review? ( ) No  ( ) Undecided  62.  I f "Yes", what are these  63.  In the f o l l o w i n g l i s t ,  programs?  a r e t h e r e any  d i s e a s e s which, i n your o p i n i o n ,  m e r i t g r e a t e r a t t e n t i o n from h e a l t h u n i t s and M.H.O.s?  (Please  the d i s e a s e s which m e r i t g r e a t e r a t t e n t i o n ) . 1.  I n f e c t i o n s and  parasitic  diseases.  2.  Neoplasms.  3.  Endocrine,  4.  Hypertension  5.  Neurologic  6.  C i r c u l a t o r y , r e s p i r a t o r y , d i g e s t i v e and  7.  Pregnancy, c h i l d b i r t h and  n u t r i t i o n a l and m e t a b o l i c and  diseases,  hematologic d i s o r d e r s .  disorders.  puerperium,  G-U  problems,  circle  7-9  63.  (continued) 8.  S k i n and musculo s k e l e t a l d i s o r d e r s .  9.  C o n g e n i t a l and p e r i n a t a l d i s o r d e r s .  10.  64.  Other ( S p e c i f y )  Are t h e r e any f e a s i b l e programs which you a r e not now u s i n g t h a t c o u l d be e f f e c t i v e i n p r e v e n t i n g these d i s e a s e s ?  (Please i n d i c a t e which of  those  d i s e a s e s which you have chosen have f e a s i b l e p r e v e n t i v e programs, by circling  the a p p r o p r i a t e  number). Disease  1. 65.  2.  3.  4.  5.  6.  7.  8.  9.  10.  Could you d e s c r i b e these programs b r i e f l y ?  Thank you f o r p a r t i c i p a t i n g participate  i n the time budget  Name: ( O p t i o n a l )  i n t h i s q u e s t i o n n a i r e and I hope you w i l l  study.  81  TIME STUDY  DAY  TIME 8:30-9:00 9:00-9:30 9:30-10:00 10:00-10:30 10:30-11:00 11:00-11:30 11:30-12:00 12:00-1:00 1:00-1:30 1:30-2:00 2:00-2:30 2:30-3:00 3:00-3:30 3:30-4:00 4:00-4:30 4:30-5:00 5:00-5:30  ACTIVITY  

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